Public Agencies Research Articles

Project and knowledge management at European public space agencies: The need for a three-dimensional project management office

Space agencies are continuously developing new space missions, each of which undergoes a long development cycle, from the feasibility study to routine operations and disposal, as per the European Cooperation for Space Standardization (ECSS), the body responsible for developing and maintaining a set of standards for the space industry in Europe. Each mission is a stand-alone project, where the development cycle starts every time from scratch, with new resources, technologies, and requirements, applying the same (tailored) standards, but with limited usage of lessons learnt from earlier or parallel projects. In this article, we analyse typical project management and knowledge management approaches adopted by public space agencies, making use of a relevant case study in Europe. From the results of our case study analysis, we propose a three-dimensional Project Management Office (PMO) governance, explaining how this novel approach helps address limitations and challenges of the current approaches when dealing with multiple complex projects, such as space missions. With the PMO defined as an organisational body or entity assigned various responsibilities, the authors focus on three specific areas, namely, Strategy, Resources, and Knowledge, as three key drivers that can improve the current management of projects of the organization.

Prevalence of HTLV-1 and 2 infection in the blood donor population of Colombia during 2012 to 2022.

e22528 Background: The HTLV-1 and 2 virus are oncogenic retrovirus with a global distribution. Viral infection is primarily associated with two conditions: HTLV-1-associated myelopathy and adult T-cell lymphoma. Although Colombia is an endemic country for the virus, data on its incidence, prevalence, and the population characterization of infected individuals are limited. Methods: This is a descriptive observational study of a retrospective cohort from a blood donor population of Fundación Hematológica de Colombia from 2012 to 2022, to determine the seroprevalence of HTLV-1 and 2 in this population. Demographic and clinical variables such as age and gender were described to characterize the seropositive population and identify specific populations, such as women of childbearing age who are seropositive for the virus. Results: During the study 1,553,478 patients were recruited, of which 3,484 were seropositive, representing a global prevalence of 0.22% over 10 years. The annual incidences were as follows: from 2012 to 2013, 0.22%; from 2014 to 2015, 0.26%; 2016 to 2017, 0.23%; 2018 to 2019, 0.25%; 2020 to 2021, 0.15%; and in 2022, 0.12%. Among the seropositive individuals, 58% were women, and 42% were men. In the donor population studied, the order of prevalences by city was as follows: Bogotá with 48%, Ibagué 13%, Barranquilla 7%, Pasto 5%, Villavicencio 4%, Pereira 3%, Soacha 3%, Tunja 2%. The average age for seropositive women and men was 22 years. 54% of seropositive women were within the reproductive age. Conclusions: Our cohort has a higher seroprevalence compared to North America. In Colombia, the two cities with the highest prevalence are the capital of the country and the city of Ibagué in our study. From a public health perspective, it is noteworthy that approximately 1100 seropositive women for HTLV-1 and 2 are in reproductive age and could potentially transmit the oncogenic virus through vertical transmission or breastfeeding. With our results it would be in the interest of public health agencies to report positive results to women of child bearing age and positive donors to begin health counseling as soon as possible.

Impact of the COVID-19 pandemic on infectious diseases reporting.

COVID-19 pandemic had impacted the reporting of notifiable communicable diseases. Since the beginning of the pandemic and the introduction of relate public health measures, notifications for most notifiable diseases have declined compared to previous years. In this study, we aim to quantify the changes in the incidences of notifiable infectious diseases during and after the pandemic in Siracusa Local Health Authority, Italy. We collected and analysed the infectious disease notifications made in two different three-years periods, 2017-2019 and 2020-2022 in Siracusa Local Health Authority, Italy. Descriptive statistics were used to find the percentages and the 95% confidence interval (CI). Exact "F-tests" was performed to compare the mean values between the studied periods to evaluate the hypothesis that the number of reported cases would not differ significantly between the two periods. Significance was assessed at the p < 0.05 level. The total number of notifications significantly decreased by 69.3% in the pandemic period compared to the pre-pandemic one, with the highest reduction of air-borne transmission diseases (-86.5%), followed by food-borne diseases (-68.2%) and sexually transmitted diseases (-39.3%). Conversely, an increase in number of notifications was found only for legionellosis. The COVID-19 pandemic had the potential to influence communicable disease reporting at multiple points. While the effects could vary considerably, the results would be expected to reduce the number and the detection of notifiable cases. Included would be changes in exposures, diagnostic testing, reporting to public health agencies, and public health investigations.

Reimagining Public Health: Mapping A Path Forward.

The COVID-19 pandemic and other ongoing public health challenges have highlighted deficiencies in the US public health system. The United States is in a unique moment that calls for a transformation that builds on Public Health 3.0 and its focus on social determinants of health and partnerships with diverse sectors while also acknowledging how the pandemic altered the landscape for public health. Based on relevant literature, our experience, and interviews with public health leaders, we describe seven areas of focus within three broad categories to support transformational change. Contextual areas of focus include increasing accountability and addressing politicization and polarization. Topical areas of focus highlight prioritizing climate change and sharpening the focus on equity. Technical areas of focus include advancing data sciences, building the workforce, and enhancing communication capacity. A transformed public health system will depend highly on leadership, funding incentives, and both bottom-up and top-down approaches. A broad effort is needed by public health agencies, governments, and academia to accelerate the transition to a next phase for public health.

Oral cancer: analysis of the clarity of publications in Instagram profiles of official health agencies in Brazil.

This article aims to analyze the clarity and engagement measures of publications on oral cancer in the Instagram profiles of official health agencies in Brazil. An infodemiological study was conducted with 81 profiles. Data collected concerned content classification, account and media, manner of addressing the topic, number of posts, likes, comments, views and hashtags. The clarity of the educational publications was assessed with the Brazilian version of the Clear Communication Index (BR-CDC-CCI). Data analysis involved Spearman's correlation and the Mann-Whitney test (α = 5%). A total of 775 publications on oral cancer were found. The average BR-CDC-CCI score was 69.8 (SD = 15.5). The clarity of the information was adequate in 9.5% of the educational publications. Positive correlations were found between the number of likes and engagement (comments [r = 0.49], views [r = 0.96]), number of hashtags (r = 0.13) and year of publication (r = 0.21). Publications from the Health Ministry had a significantly higher BR-CDC-CCI score compared to the other profiles. Publications on oral cancer were correlated with engagement, year of publication and number of hashtags. Public agencies increased publications to reach the population, but the clarity of the content was low.

LEGAL PROTECTION FOR SOCIAL SECURITY ADMINISTERING BODY HEALTH PARTICIPANTS

In order to legally protect the rights of patients participating in the Social Security Administering Body (BPJS) of Health in obtaining health services, the government issued Law Number 24 of 2011, which stipulates that two state-owned enterprises, namely PT Askes (Persero) and PT Jamsostek (Persero) were transformed into public service agencies to implement five programs mandated by Law Number 40 of 2004, namely the health insurance program for BPJS Health and other programs are handed over to BPJS Employment. This study aims to analyze how to protect BPJS Health participants. This study uses a normative legal research method with field data as a complement. The results of the study Legal protection for BPJS Health participants who are hospitalized in hospitals from the regulatory aspect have protected their rights both as consumers of services, as hospital patients and as BPJS Health participants. The method of resolving BPJS Health service disputes through mediation reflects the importance of a consensual approach to dispute resolution. Mediation is chosen for several theoretical reasons, such as the dominance of a culture that prioritizes harmony and togetherness, and the balance of power between the disputing parties.

A framework and process for community-engaged, mixed-methods cancer needs assessments

PurposeCommunity health needs assessments are required for most state and local public health agencies and non-profit hospitals. Typically based on community health improvement planning models, these assessments encompass overall community health and multiple diseases to inform program planning. National Cancer Institute (NCI)-designated Cancer Centers and community-based cancer-focused programs share the goal of reducing cancer burden in the catchment areas they serve. However, to date, no published models exist to guide cancer-specific needs assessments for a determined geographic area that can inform both public health and research initiatives. The purpose of this article is to outline a cancer needs assessment (CNA) framework and community-engaged, mixed-methods process, along with a case study of how we applied it in Kentucky.MethodsWe convened a steering committee of key organizational partners to provide input throughout the process. We developed a conceptual framework of multi-level determinants affecting cancer-related outcomes. We incorporated both quantitative and qualitative data gathered through a variety of means, including a novel application of group concept mapping to guide definition of priorities.ResultsThe resulting CNA has helped guide strategic planning and priorities for Kentucky’s Cancer Action Plan, Markey Cancer Center, state agencies, and community-based organizations.ConclusionThis framework and process can be used collaboratively by cancer center Community Outreach and Engagement offices, public health agencies, oncology programs, and community partners to plan impactful cancer control programs and research in their catchment areas. Universities can also use them to inform the planning of community engagement and health equity research efforts.

Principles for embedded emissions accounting to support trade-related climate policy

ABSTRACT Climate policy – though shaped by international regimes – has traditionally been heavily domestic in practice. Accordingly, public emissions accounting frameworks have been designed to support policies targeting emitting processes within the territory, and to facilitate the production of National Accounts. Now, a combination of emissions leakage, competitiveness, and both investor and consumer concerns are driving the rapid emergence of policies targeting emissions embodied in traded products. To support these product-targeted policies, governments are investing in the development of public embedded emissions accounting frameworks (EEFs). While EEFs as an information instrument have enormous potential to support the transition to a net-zero global economy, they equally have the potential to inhibit trade, slow the transition, and have a disproportionate impact on developing countries – both through their design, and through potential incompatibilities between accounting developed in different jurisdictions. This article contributes to addressing these challenges by describing the minimum viable set of principles for an emissions accounting information instrument to be compatible with both international trade law and climate change mitigation regimes. To identify these design principles, our method is a systematic review of carbon accounting and trade law literature. Noting the prominent place of principles in guidelines for carbon accounting practice, we additionally extract principles identified in leading emissions accounting guidelines. Theory-based identification and analysis of these systematically extracted principles is used to develop the synthesized set of key principles for the design of public embedded emissions accounting schemes for traded products. Public agencies developing approaches for product emissions accounting, such as to meet requirements for carbon border adjustment mechanisms, could use these principles to guide design and negotiation.

Silversol® (a Colloidal Nanosilver Formulation) Inhibits Growth of Antibiotic-Resistant Staphylococcus aureus by Disrupting Its Physiology in Multiple Ways.

Antibiotic-resistant strains of Staphylococcus aureus are being viewed as a serious threat by various public health agencies. Identifying novel targets in this important pathogen is crucial to the development of new effective antibacterial formulations. We investigated the antibacterial effect of a colloidal nanosilver formulation, Silversol®, against an antibiotic-resistant strain of S. aureus using appropriate in vitro assays. Moreover, we deciphered the molecular mechanisms underlying this formulation's anti-S. aureus activity using whole transcriptome analysis. Lower concentrations of the test formulation exerted a bacteriostatic effect against this pathogen, and higher concentrations exerted a bactericidal effect. Silversol® at sub-lethal concentration was found to disturb multiple physiological traits of S. aureus such as growth, antibiotic susceptibility, membrane permeability, efflux, protein synthesis and export, biofilm and exopolysaccharide production, etc. Transcriptome data revealed that the genes coding for transcriptional regulators, efflux machinery, transferases, β-lactam resistance, oxidoreductases, metal homeostasis, virulence factors, and arginine biosynthesis are expressed differently under the influence of the test formulation. Genes (argG and argH) involved in arginine biosynthesis emerged among the major targets of Silversol®'s antibacterial activity against S. aureus.

Determinants of COVID-19 vaccine uptake in Kwara State, Nigeria: The role of public health management professionals in driving behavioral change

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has been a global concern since the onset of the pandemic. Vaccination has emerged as an effective intervention to prevent infection, alleviate severe clinical symptoms, and reduce mortality rates. COVID-19 vaccines, approved by the World Health Organization and other health regulatory bodies, have been administered worldwide, including in Nigeria. However, vaccine hesitancy has hindered the widespread uptake of the COVID-19 vaccine. This study, conducted between December 2021 and May 2022, aimed to assess factors influencing COVID-19 uptake within public health-care settings and the roles of health-care professionals in influencing vaccine uptake. A total of 366 health workers from randomly selected primary health centers in the Ilorin metropolis participated in this study, responding to the Barrier Analysis questionnaire. Chi-square analysis was utilized to determine relationships between variables and their significance. Our findings revealed trust in vaccines (100%), access to vaccination centers (93.3%), health-care professionals&amp;rsquo; recommendations (85.5%), and education level (86.9%) as major determinants of vaccine uptake among health-care workers in Ilorin, Kwara State. Other factors included religious belief (99.3%) and family approval (97.6%). In conclusion, education, vaccine safety perception, access to vaccination centers, family approval, and health-care workers&amp;rsquo; recommendations are key factors influencing behavioral changes toward COVID-19 vaccine uptake among health-care workers in Ilorin, Kwara State. The study recommends that public health agencies and the health ministry focus on these factors in policy formation to improve COVID-19 vaccine uptake in Kwara State and Nigeria as a whole.

Enhancing the epidemiological surveillance of SARS-CoV-2 using Sanger sequencing to identify circulating variants and recombinants

Since the emergence of SARS-CoV-2 in December 2019, more than 12,000 mutations in the virus have been identified. These could cause changes in viral characteristics and directly impact global public health. The emergence of variants is a great concern due to the chance of increased transmissibility and infectivity. Sequencing for surveillance and monitoring circulating strains is extremely necessary as the early identification of new variants allows public health agencies to make faster and more effective decisions to contain the spread of the virus. In the present study, we identified circulating variants in samples collected in Belo Horizonte, Brazil, and detected a recombinant lineage using the Sanger method. The identification of lineages was done through gene amplification of SARS-CoV-2 by Reverse Transcription-Polymerase Chain Reaction (RT-PCR). By using these specific fragments, we were able to differentiate one variant of interest and five circulating variants of concern. We were also able to detect recombinants. Randomly selected samples were sequenced by either Sanger or Next Generation Sequencing (NGS). Our findings validate the effectiveness of Sanger sequencing as a powerful tool for monitoring variants. It is easy to perform and allows the analysis of a larger number of samples in countries that cannot afford NGS.

Navigating ADA Compliance

Problem, research strategy, and findings The Americans with Disabilities Act (ADA), passed in 1990, set requirements that public agencies in the United States, which receive federal funds, must remove physical barriers in the public right-of-way that might prevent someone with a disability from accessing goods and services. ADA’s impact on transportation extends from equitable access in public transportation to meeting compliance requirements for curb ramps at intersections. Researchers argue that public agencies are still falling behind in ADA implementation due to scarce funding, inadequate asset inventory development, and limited transition/compliance plans. We asked: What can organizations and practitioners do to improve ADA implementation for infrastructure design and supply? We relied on an online survey (n = 206) and semistructured interviews (n = 36) with transportation practitioners across the United States. The findings revealed that ADA implementation has been thwarted due to three primary themes that make meeting ADA implementation in transportation challenging: 1) political priorities and organizational coordination that limit ADA in practice; 2) limited guidance, resources, and capacity; and 3) challenges with retrofits, new construction, and maintenance. Takeaways for practice Our work suggests that organizations and practitioners wish to expand ADA implementation, but to achieve this, additional monetary resources and employee training are needed. Requiring ADA asset inventories and compliance plans, along with developing a framework to improve accessibility from project conception to postdelivery, could incentivize widespread ADA implementation.

ESG rating results and corporate total factor productivity

As a measure of corporate environmental, social, and governance (ESG) performance, ESG ratings have increasingly gained attention from corporations, the public, and government agencies, gradually becoming a key factor influencing their perceptions and decision-making regarding corporations. This study explores the impact of corporate ESG ratings on Total Factor Productivity (TFP) and its underlying mechanisms. Using listed companies in China as the research sample, it was found that higher ESG ratings significantly enhance corporate TFP, a conclusion that holds even after conducting robustness checks and addressing endogeneity issues. Further analysis indicates that high ESG ratings improve corporate TFP by reducing financing constraints and increasing government subsidies. Heterogeneity analysis shows that the effect of ESG ratings on enhancing TFP is more pronounced for corporations with high levels of attention, good reputations, and high audit quality. Additionally, the study also examines whether ESG ratings can serve as an effective predictor of corporate TFP. By applying machine learning algorithms for validation, the results show that incorporating ESG ratings significantly improves the accuracy of predictions for corporate TFP.

External quality assurance of cost estimates in major public projects: empirical evidence on cost performance

PurposeValue creation for society from public projects requires that the overall benefits exceed the use of taxpayers' money. At the same time, cost overruns in public projects are a well-documented feature in the literature, but practical guidance on reducing the extent and magnitude of overruns is rare. In 2000, Norway introduced a governance regime that includes mandatory external quality assurance (QA) of cost estimates for major public projects. This paper compares the cost performance of public projects on each side of this QA scheme.Design/methodology/approachWe use an original dataset covering 1,704 projects from 2000 to 2021, reported first-hand from Norwegian public agencies. We apply quantitative methods in the form of descriptive statistics, regression models, and statistical testing of hypotheses to answer our research questions.FindingsThe mean cost overrun across projects in our dataset is smaller than several previous international studies have reported. We find no statistical support for different cost performances between QA and non-QA projects. Secondly, cost overruns seem to vary between different public sectors. A third finding is a small development with lower cost overruns over time for the non-QA projects, and we raise the question of whether the QA scheme has contributed to overall learning effects. The fourth finding is that cost deviations are quite independent of project size.Originality/valueThe paper offers novel insights for decision-makers and researchers on the effects of external quality assurance on cost performance in public projects.

Justice Delayed is Justice Denied: Managing Contracting Performance for Equal Employment Opportunity Discrimination Complaints

Public agencies often use contractors to facilitate Equal Employment Opportunity (EEO) discrimination complaint cases, but we know relatively little about which factors influence contracting performance of the complaint process. Drawing on contracting theories, this study examines two factors—incentive structure and contractor ownership (i.e., women-owned and small disadvantaged-owned)—that moderate the link between agency contracting use and agency performance in the discrimination complaint process. Using the agency-level panel data from multiple sources, this study finds agency contracting use facilitates the discrimination complaint process when agencies use a performance-based incentive structure. When it comes to the moderating effect of contractor ownership focused on the socially/economically underrepresented, the findings show that using small disadvantaged-owned contractors positively moderates the relationship between contracting use and performance at the agency level.

Initiating, enacting and sustaining partnerships to inform post-school pathways

ABSTRACT Partnerships with local public sector agencies, enterprises and tertiary institutions offer a means to inform young people about post-school pathways into working life and occupations that schools alone cannot achieve. Informing about those pathways is an important, yet, complex educational goal for schooling. This is because much of schooling effort privileges and is directed towards higher education entry. Often advice provided to young people through schools is by teachers and administrators who are, understandably, unacquainted with the range of post-school pathways other than higher education. School guidance officers report being ill-equipped and unable to provide students personalised advice. Consequently, sources of advice and experiences beyond the school are now being utilised, particularly through the growing role of partnerships. These partnerships take diverse forms and comprise different kinds of institutional alignments and are increasingly being viewed as essential bases for supporting effective and informed post-school transitions. This article presents and discusses a review of literature and a recent investigation to advance principles and practices of how such partnerships can be best initiated, enacted, and sustained over time and they can meet the goals of informing and guiding young people’s pathways, including options other than progression to higher education.

State-of-the-Practice of a State Utilization of Traffic Simulation: Case Study of Florida, U.S.

Traffic simulation tools are widely used in analyzing and enhancing the forecasting, planning, design, operations, and management of transportation systems. Despite the increasing use of traffic simulation through the years, there are still many needs and issues facing transportation agencies and modelers in their use of traffic simulation. These needs and issues have not been sufficiently surveyed and summarized in the literature. The goal of this study is to identify the current applications, needs, and issues of traffic simulation modeling based on a survey of public and private agencies in Florida, U.S. The study conducted an online survey of traffic simulation modelers in Florida, followed by phone interviews with a subset of the respondents to the survey. The survey addressed the types of the utilized traffic analysis and simulation tools, utilized simulation guidance, utilized traffic data and performance measures, calibration processes and resources utilized by agencies, the current practice of future year demand forecasting, and perspective on the simulation of emerging technologies. The results from this study will help understand the present situation of applying traffic simulation and future needs to enhance simulation modeling capabilities and practices.

Post-market surveillance of six COVID-19 point-of-care tests using pre-Omicron and Omicron SARS-CoV-2 variants.

Post-market surveillance of test performance is a critical function of public health agencies and clinical researchers that ensures tests maintaining diagnostic characteristics following their regulatory approval. Changes in product quality, manufacturing processes over time, or the evolution of new variants may impact product performance. During the COVID-19 pandemic, a plethora of point-of-care tests (POCTs) was released onto the Canadian market. This study evaluated the performance characteristics of several of the most widely distributed POCTs in Canada, including four rapid antigen tests (Abbott Panbio, BTNX Rapid Response, SD Biosensor, and Quidel QuickVue) and two molecular tests (Abbott ID NOW and Lucira Check IT). All tests were challenged with 149 SARS-CoV-2 clinical positives, including multiple variants up to and including Omicron XBB.1.5, as well as 29 clinical negatives. Results were stratified based on whether the isolate was Omicron or pre-Omicron as well as by reverse transcriptase quantitative PCR Ct value. The test performance of each POCT was consistent with the manufacturers' claims and showed no significant decline in clinical performance against any of the variants tested. These findings provide continued confidence in the results of these POCTs as they continue to be used to support decentralized COVID-19 testing. This work demonstrates the essential role of post-market surveillance in ensuring reliability in diagnostic tools.IMPORTANCEPost-market surveillance of diagnostic test performance is critical to ensure their reliability after regulatory approval. This is especially critical in the context of the COVID-19 pandemic as the use of point-of-care tests (POCTs) became widespread. Our study focused on four rapid antigen tests (Abbott Panbio, BTNX Rapid Response, SD Biosensor, and Quidel QuickVue) and two molecular tests (Abbott ID NOW and Lucira Check IT) that were widely distributed across Canada, assessing their performance using many SARS-CoV-2 variants, including up to Omicron subvariant XBB.1.5. Overall, we found no significant difference in performance against any variant, reinforcing confidence in their use. As concerns in test efficacy have been raised by news outlets, particularly regarding the BTNX Rapid Response, this work is even more timely and crucial. Our research offers insights into the performance of widely used COVID-19 POCTs but also highlights the necessity for post-market surveillance.

Designing and implementing an experimental survey on knowledge and perceptions about alcohol warning labels.

This paper describes the design and implementation of an online survey experiment to investigate the effects of alcohol warning labels on alcohol-related knowledge, risk perceptions and intentions. The survey collected self-reported data from 14 European countries through two waves of data collection with different recruitment strategies: dissemination via social media and public health agencies was followed by paid-for Facebook ads. The latter strategy was adopted to achieve broader population representation. Post-stratification weighting was used to match the sample to population demographics. The survey received over 34,000 visits and resulted in a sample size of 19,601 participants with complete data on key sociodemographic characteristics. The responses in the first wave were over-representing females and higher educated people, thus the dissemination was complemented by the paid-for Facebook ads targeting more diverse populations but had higher attrition rate. Experiments can be integrated into general population surveys. Pan-European results can be achieved with limited resources and a combination of sampling methods to compensate for different biases, and statistical adjustments.

Chemometric Analysis and Human Health Implications of Trace and Heavy/Non-Essential Metals through ingestion of Carbonated and Non-Carbonated Beverages.

Elevated levels of trace metals (TMs) and heavy/non-essential metals (HnMs) in commonly consumed beverages concern the public and regulatory agencies. Thus, frequent monitoring of these metals is critically important. The present study intended to assess TMs and HnMs concentrations and associated health risks in beverages. Ten metals, such as Mn, Co, Cr, Cu, and Zn (TMs) and Ni, Cd, Pb, Al, and As (HnMs), were quantified in different beverage brands categorized into two groups such as non-carbonated and carbonated beverages. Chemometric analysis such as hierarchical cluster analysis (HCA), Pearson's correlation coefficient (PCC), and principal component analysis (PCA) were also performed to demonstrate the possible natural and anthropogenic sources of metal contamination. Among the TMs, the mean concentration of Zn (233.3 ± 3.3-291.7 ± 3.2µg/L) followed by Mn (119.0 ± 2.3-146.4 ± 2.2µg/L) was found highest in both carbonated and non-carbonated beverage samples. In the case of HnMs, the lowest mean concentration of Cd (7.4 ± 0.9-18.6 ± 1.2µg/L) followed by Pb (4.1 ± 0.4-4.5 ± 0.4µg/L) was observed in both types of beverage samples. The tolerable dietary intake (TDI) value for Ni and provisional tolerable monthly intake (PTMI) value for Cd were higher than the value established by the WHO and EFSA. The computed values of the hazard index (HI < 1) and the cumulative cancer risk (CCR) indicated a low risk of exposure.