2020. 2. 18. 01:49ㆍ카테고리 없음
Results Of 1,997 febrile patients, 475 (23.8%) were positive by expert microscopists, with 57.7% P.falciparum, 24.6% P.vivax and 17.7% mixed infections. Sensitivity of health center microscopists for any malaria species was 90% in five health centers (four of which had the highest prevalence), 70% in nine centers and 44% in one site with lowest prevalence.
Specificity for health center microscopy was very good (95%) in all centers. For ParaScreen RDT, sensitivity was ≥90% in three centers, ≥70% in six and. Conclusions Health center microscopists performed well in nine of the ten health centers; while for ParaScreen RDT they performed well in only six centers. Overall the accuracy of local microscopy exceeded that of RDT for all outcomes. This study supports the introduction of RDTs only if accompanied by appropriate training, frequent supervision and quality control at all levels. Deficiencies in RDT use at some health centers must be rectified before universal replacement of good routine microscopy with RDTs.
Maintenance and strengthening of good quality microscopy remains a priority at health center level. Introduction Accurate early case detection and prompt treatment with appropriate antimalarial drugs is the major strategy for effective case management in malaria patients. Correct diagnosis is also vital for the malaria prevalence and incidence indicators used to evaluate the impact of malaria control interventions. A parasite based diagnostic test (microscopy or rapid diagnostic test RDT) is now recommended, if available, instead of presumptive treatment for all persons with suspected malaria.
While this recommendation has been adopted in the latest version of the Ethiopia treatment guidelines, diagnostic test facilities are not always available and their quality has not been comprehensively assessed or compared under routine conditions. We previously reported two studies on ParaScreen Pf/PAN RDT in Ethiopia, one from a large household survey in mainly asymptomatic persons and one from ten health centers in Amhara region.
ParaScreen can distinguish between a P.falicparum (or mixed) infection, and a non P.falciparum infection. The sensitivity of ParaScreen compared to expert microscopy was relatively low in the household survey, but it performed better for persons with suspected malaria in the health facilities in Amhara region. The health facility study directly compared two RDTs, ParaScreen and ParaCheck (detects P.falciparum only), done by the health center technicians with the results on the same individuals by expert microscopy.
The ratio of P.falciparum to P.vivax was 64% to 46%. The findings indicated that overall, ParaScreen had adequate performance of 80% sensitivity for P.falciparum and 74% for P.vivax, with 97% and 99% specificity respectively. ParaCheck also performed well for P.falciparum but it is not designed to detect P.vivax, and has been replaced with multi-species RDTs supplied to all health posts (which do not have microscopy) in Ethiopia.
The higher level Health Centers and Hospitals retain the use of microscopy for malaria diagnosis. A recent study at three health centers in Oromia region observed slightly higher sensitivity but lower specificity for P.falciparum by ParaScreen (85.6% and 92.4% respectively) compared to expert microscopy than we previously observed in Amhara. For P.vivax they observed 82.5% sensitivity and 96.2% specificity with ParaScreen. Overall regardless of other parameters used for comparing the performance of three RDTs, ParaScreen performed similarly to two other tests (CareStart and ICT Combo) for P.falciparum but CareStart had better specificity for P.vivax.
The slide positivity rates among patients with suspected malaria by expert microscopy were very similar in the two studies (23.8% in Amhara and 23.2% in Oromia regions 7). Although in our previous study ParaScreen performance was acceptable overall in the Amhara health centers, variation was noted between health centers in the accuracy of both microscopy and RDT compared to the expert microscopists. This variation in performance at health center level is important because in Ethiopia, RDTs are routinely done at health posts (where microscopy is not available) by health extension workers, and immediate supportive supervision for these workers is expected to be provided by the cluster heath center staff at their respective catchment health posts. In addition during times of emergency, failure of microscopes and/or shortage of reagents, multispecies RDTs have to be used in the health centers, so detailed know-how on the performance of multispecies RDTs by the health center technicians is crucial.
Therefore, we build on the previously reported results and conduct additional analysis with three aims:. Ethical Considerations The study protocol received ethical approval from the Emory University Institutional Review Board (IRB 00006389) and the Amhara Regional Health Bureau (Reference No.
Verbal informed consent was sought from each individual and from parents of children aged under 18 years; assent was sought from children 6 to 18 years in accordance with the tenets of the Declaration of Helsinki. All positive cases were treated at their respective health centers according to the treatment guidelines for malaria infection in Ethiopia. Personal identifiers were removed from the data set before the analyses were undertaken. Location of health centers included in the study in Amhara National Regional State, Northwest Ethiopia. In each health center the first 200 self-presenting patients of any age and either sex who qualified as clinically presumptive malaria (i.e. An axillary temperature greater than or equal to 37.5°C or history of fever in the previous 48 hours) were recruited to the study after excluding individuals with other known causes of non malarial febrile illnesses or serious illness. After obtaining informed consent demographic data were recorded on a structured questionnaire and a finger-prick blood sample taken for blood film preparation and ParaScreen RDT processing.
Training Among the ten technicians involved in this study, two held a university degree (BSc in medical laboratory technology) and the other eight held a diploma (or advanced diploma) in medical laboratory technology. Nine technicians had a minimum of five years’ experience in malarious areas and the other had two and a half years’ experience. All the technicians who participated during the training were from government health centers and had previous exposure and experience working with a monospecies malaria RDT (Paracheck Pf) that detects Pf only in their respective health centers. The training, conducted for half a day at each health center, focused on technical operation of multispecies RDT (ParaScreen) based on the manufacturer’s instruction, and procedure for standard blood smear preparation. This included how to handle RDTs, how to collect blood from finger prick for both RDT and smear preparation, how to use buffer for RDT, and RDT reading and interpretation. The procedures for blood films (thin and thick) preparation, staining and species identification were briefly addressed. During training before sample collection was started, simplified and detailed standard operating procedures (SOP) on both RDT and blood slide preparation and staining were prepared and distributed to all health centers that have participated in this study.
Similarly, agreement was reached with registered health officers and clinical nurses about the selection criteria of febrile patients with suspected malaria that fulfill the requirement of the study. It was also agreed with the health officers and nurses that all patients involved in the study would be treated according to the malaria treatment algorithm and national guideline of the country. The centers were visited four times during sample collection and processing, and there was frequent telephone communication whenever there was a need to clarify study related issues or during shortage of materials to be replaced. Rapid Diagnostic Tests Patients were tested with ParaScreen Pan/Pf® (Zephyr Biomedical systems, Verna, Goa, India) device according to the manufacture’s instruction.
ParaScreen RDT had long expiry dates (6 months or more) and were stored according to the manufacturer’s recommendations (4–30°C). Tests with no band at the control line were considered invalid. Band formation on the Pan-line only was considered to be evidence of non-falciparum malaria (presumably P. Vivax infection) whilst bands at both Pan and Pf were considered P.falciparum or mixed infections. Statistical analysis Statistical analysis was conducted using SPSS version 15.0 (IBM ) and RevMAN 5.1 (Review Manager (RevMan) Computer program.
Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011). The performance of health center microscopy and of ParaScreen RDT was determined by calculating the sensitivity, specificity, positive predictive value and negative predictive value against reference laboratory microscopy as the gold standard. Sensitivity was calculated as the proportion of positive test results against true positives; specificity was calculated as a proportion of negative test results against true negatives. The positive predictive value was calculated as a proportion of true positive results among all positively reacting samples and the negative predictive was calculated as the proportion of true negative results among all negatively reacting samples. Proportions were compared using the chi-squared test. Summary receiver operator characteristic curves (SROC) were prepared in RevMAN for the two comparisons (local microscopy vs expert microscopy; RDT vs expert microscopy) and presented side by side for each of three outcomes (any malaria positive, P.falciparum or mixed, P.vivax or PAN only) by health center.
Results Locations of the health centers are shown in. Out of 2000 recruited patients, 1997 febrile cases were examined for malaria parasites by blood slide microscopy (198 to 200 per health center). Out of these, 56.2% were males and the remaining were females. The age range was 8 months to 85 years with a mean of 20.7 years.
Of the 1997 persons tested by slide, 1993 samples were also examined by ParaScreen RDT at the health centers. During supervisory visits to the health centers, it was observed in some health centers that the technicians were overloaded with different laboratory work due to high flow of outpatients seeking treatment and laboratory tests. The results for all the health centers combined are shown in the flow chart in. By expert microscopy (the gold standard), 23.8% of the 1997 patients tested were positive for malaria parasites, with a range from 4.5% to 55.5% by health center ( and ).
Results for health center microscopy were overall 22.3% positive (N = 1997) with a range of 3.0 to 54.1%; and for ParaScreen RDT 22.2% positive (N = 1993) with a range of 4.5 to 49.5%. These differences between expert microscopists, health center microscopists and RDTs in overall percent positive are not statistically significant. However, they mask significant variation at the health center level. Prevalence of malaria by expert microscopists, by health center and species. Altitudinal variation in relation to malaria slide positivity is shown in.
In general there was a declining trend of positivity rate with altitude, with the lowest rates being observed at altitudes higher than 2000 meters above sea level, but there were two health centers between 1750 and 2000 meters above sea level with high slide positivity rates (Ambessame with 51.5% and Kola Diba with 35% slide positivity rate). The possible explanation for high malaria positive rate in these two health centers at high altitude could be that the majority of the patients were from the catchment villages of lower altitude of known malarious areas.
Health Center Microscopy Compared to Expert Microscopy The majority of infections (57.7%) detected by expert microscopists were P.falciparum only, with 24.6% P.vivax and 17.7% mixed infections ( and ). The overall ratio of P.falciparum to P.vivax (1.78∶1 for the experts) was comparable for the health center microscopists (1.69∶1). By individual health center, overall percent positive was not significantly different between health center and expert microscopists in any health center.
However the general concordance in slide positive rate mentioned above and shown for the total sample in does not represent the complete picture, since there was not complete overlap in the positives or the species identified by the two sets of microscopists. Expresses the sensitivity and specificity for the outcome of malaria positive (any species) at each health center against expert microscopy, and shows the results in Summary Receiver Operator characteristic (SROC) format. The positive and negative predictive values are given in. Health center microscopy compared to expert microscopy: any malaria species.
The overall sensitivity of microscopy for any malaria species by the health center microscopists was 88.4% (95% CI 85.2–91.2) and the specificity was 98.4% (95% CI 97.6–98.9). In the six health centers with highest prevalence (Shinifa, Ambessame, Kola Diba, Woreta, Deligi and Alember), sensitivity was greater than 90% in five of them and above 80% in Kokit. In three of the medium transmission areas (Meruto-Lemariam, Yejube and Alember), sensitivity of 70 to 80% was observed. Notably, shows very poor sensitivity by the health centre microscopist of 44.4% (95% CI 13.7–78.8) at Jiga health center, which had the lowest positivity rate of all the centers.
Specificity was above 95% at all the centers. And show the equivalent results for the comparison of health center microscopy versus expert microscopy for P.falciparum or mixed infections. Positive and negative predictive values are given in.
Sensitivity for P.falciparum was above 80% in 7 of the 10 centers, and specificity was 98% or higher in all. Two sites (Yejube and Jiga) had relatively low sensitivity for P.falciparum (. ParaScreen Rapid Diagnostic Test Compared to Expert Microscopy For any malaria species , the overall sensitivity of RDTs was 79.4%. Only 3 of the health centers (Ambessame, Kola Diba and Woreta) had sensitivity over 90%), two (Kokit and Meruto Lemariam) were between 80 and 90%, one (Shinfa) was 79% and the other four were below 60% sensitivity.
Specificity was very good overall with the exception of Meruto Lemarian with 86% specificity. The SROC curves for the outcomes of malaria positive (any species) are shown in while positive and negative predictive values are in.
Rapid Diagnostic Test (Pf/PAN or PAN) compared to expert microscopy: any malaria species. The proportion of positives (any species) detected by RDT was significantly lower than the expert microscopists at two health centers: Shinifa (44% RDT vs 55.5% expert microscopy, Chi-sq = 5.29, p = 0.021) and Deligi (7.1% RDT vs 13.6% expert microscopy, Chi-sq = 4.60, p = 0.032), while percent positive was higher by RDT at Meruto Lemariam (21.1% RDT vs. 13.2% expert microscopy, Chi-sq = 4.49, p = 0.034). The others were not significantly different. For P.falciparum or mixed infection sensitivity and specificity are shown in, SROC in and PPV and NPV given in. Four of the health centers (Deligi, Alember, Yejube and Jiga) with lower prevalence (see ) performed poorly with RDTs. Meruto Lemariam was the exception among the health centers with low prevalence in achieving very good sensitivity for P.falciparum, although at the expense of specificity.
ParaScreen Rapid Diagnostic Test Compared to Health Center Microscopy Only indirect comparison is possible because the same technicians conducted both tests in each health center, which compromised the blinding. The relative accuracies of health centre microcopy and RDT for each of three outcomes (any species, Pf or mixed, Pv) are shown in the Summary ROC curves in, and respectively. In each case the RDT predicted curve lies to the right and below (less accurate) that for HC microscopy. The five sites with highest prevalence were relatively consistent in giving good or very good performance for both microscopy and RDT compared to expert microscopy.
However overall, the performance of RDT was not as good as health center microscopy, and it was particularly poor in the five sites with lower prevalence. As expected, the RDTS performed in general less well for P.vivax than P.falciparum. Discussion Rapid diagnostic tests are being strongly promoted for wider use to ensure that all suspected malaria cases receive a diagnosis before treatment. Most RDT studies have tested whether RDTs are as accurate as expert microscopy, and these previous studies were mostly designed to assess the performance of the tests per se, rather than their accuracy in routine use. There have been few evaluations of the accuracy of RDTs compared to the status quo of routine health center microscopy, or of variation in performance of both routine microscopy and RDT between sites. The results of such studies point to differences in strict application of knowhow gained during training and previous work experience in malarious areas (for both methods) as well as storage or other possible factors that affect the correct use of RDTs. Even if RDTS are not as good as expert microscopy, in some cases they may be better than routine microscopy.
In this study we address this issue indirectly by examining the performance of both routine microscopy and RDTs as performed in ten rural health centers, compared to the gold standard of expert microscopy. Overall, microscopists in ten rural health centers in Amhara region, Northwest Ethiopia showed fair to very good performance compared to expert microscopy, with the exception of the health center with the lowest prevalence of 4.5% among suspected malaria cases. One other health center did badly with P.vivax slides only. Microscopists in health centers in these study sites of Northwest Ethiopia are performing to a standard higher than has been observed in some other malaria endemic areas. However there are still some gaps and inconsistencies in microscope capacity, and lack of a standardized quality control system for diagnostics, as has been observed by others. For RDTs, there was large variation between sites in the performance, with generally lower performance than for local microscopy, when each is compared to expert microscopy. Four of the ten sites (of the five with less malaria) performed very poorly on RDT sensitivity in general, and the other was very poor for P.vivax.
Even one of the sites with high prevalence demonstrated only a fair level of sensitivity with RDTs. Sensitivity of the test (unlike positive predictive value) should not be affected by prevalence. A decrease in positive predictive value for RDT in one site with lower prevalence was also observed in Uganda. During supervisory visits it was noted that although the technicians were observed to be proficient in performing the tests according to standard operating procedures, they were overloaded with the many other lab tests they are expected to perform in addition to malaria diagnosis. Under real world conditions, when pressed with large numbers of patients, they may use rapid staining methods and skimp on slide examination time or number of fields to be examined (especially if densities are low) just to satisfy the clients. Low prevalence in an area with few requests for malaria diagnosis gives the technician limited ability to maintain his or her skills in parasite identification by microscopy, or to practice reading and interpreting faint positive RDT tests.
More quality control checks and frequent refresher trainings are needed in low incidence areas, or as malaria incidence declines due to extensive control efforts. Overall our results demonstrate slightly lower sensitivity with RDTs than has been observed in Ethiopia and elsewhere,. The low sensitivity with ParaScreen in some sites means that cases are being missed while high false positive rates means that persons without malaria (and possibly with other infections) are getting treated for malaria in some sites. These findings suggest that there are deficiencies in strict application of training materials, lack of previous skill in performing multispecies RDTs, and/or possible problems in RDT handling conditions in some sites, in addition to large demands on technicians’ time for other lab tests.
Where no adequate and standard malaria microscopy exists (for example in health posts staffed by Health Extension Workers in moderate to high malarious areas), this study supports the introduction of multispecies RDTs for improvement of diagnosis of malaria, provided that they are accompanied by adequate training on procedure and limitations of the tests, as well as continual supervision and overall quality control mechanisms. However, microscopy in rural health centers remains the local ‘gold standard’ and should not be neglected for refresher training and supervision especially where problems are identified in particular centers as in this study.
Ash Carter 25th In office February 17, 2015 – January 19, 2017 President Deputy Preceded by Succeeded by 30th In office October 6, 2011 – December 3, 2013 President Preceded by Succeeded by (Acting) In office April 27, 2009 – October 5, 2011 President Preceded by Succeeded by In office June 30, 1993 – September 14, 1996 President Preceded by Succeeded by (2001) Personal details Born Ashton Baldwin Carter ( 1954-09-24) September 24, 1954 (age 63), U.S. Political party Spouse(s) (divorced) Stephanie DeLeeuw Relations (sister) Children 2 Education (, ) Ashton Baldwin ' Ash' Carter (born September 24, 1954) is an American and former professor of Science and International Affairs who served as the 25th from February 2015 to January 2017. He was nominated by President, and confirmed in February 2015 by the by a vote of 93–5, to replace as Secretary of Defense. Carter received a B.A.
In his double-major of Physics and Medieval History from, in 1976. He then became a and studied at the, from which he received his in in 1979. He worked on, the that was then postulated to explain the behavior of and the structure of. He was a postdoctoral fellow research associate in theoretical physics at from 1979 to 1980 and a at the from 1982 to 1984.
Carter taught at, beginning in 1986. He ultimately rose to become chair of the International & Global Affairs faculty and Ford Foundation Professor of Science & International Affairs at the within the. Carter is author or co-author of 11 books and more than 100 articles on physics, technology, national security, and management. Carter served as during, from 1993 to 1996, responsible for policy regarding the former Soviet states, strategic affairs, and nuclear weapons policy. He was from April 2009 to October 2011, with responsibility for procurement of all technology, systems, services, and supplies, bases and, energy, and environment, and more than $50 billion annually in. He was then from October 2011 to December 2013, serving as the chief operating officer of the DOD overseeing an annual budget in excess of $600 billion, 2.4 million civilian and military personnel, and global operations.
For his service to national security, Carter has on five occasions been awarded the DOD. He has also received the, and the for his contributions to Intelligence. Contents. Early life Ashton Baldwin Carter was born on September 24, 1954, in. His father is William Stanley Carter, Jr., a veteran, neurologist and psychiatrist, and department chairman at for 30 years. His mother is Anne Baldwin Carter, an English teacher. He has three siblings, including author.
As a child he was nicknamed Ash and Stoobie. He was raised in, on Wheatsheaf Lane. At age 11, working at his first job at a Philadelphia car wash, he was fired for 'wise-mouthing the owner'.
Education Carter was educated at Highland Elementary School (class of 1966) and at (class of 1972) in Abington. In high school he was a wrestler, lacrosse player, cross-country runner, and president of the Honor Society. He was inducted into Abington Senior High School's Hall of Fame in 1989. He attended in Scotland in the spring of 1975. In 1976 Carter received a B.A. In his double-major of Physics and Medieval History from,. His senior thesis, “Quarks, Charm and the Psi Particle”, was published in in 1975.
He was also an experimental research associate at in 1975 (where he worked on research) and at in 1976. Carter then became a, studying at the, from which he received his DPhil in in 1979. He was subsequently a postdoctoral fellow research associate in theoretical physics at from 1979 to 1980, studying and.
The Carter 3 Download
He was then a at the from 1982 to 1984, during which time he wrote a public report assessing that the Reagan-proposed ' initiative could not protect the US from a Soviet nuclear attack. Academic career Carter taught at, as an assistant professor from 1984 to 1986, associate professor from 1986 to 1988, professor and associate director of the at Harvard University's from 1988 to 1990, and director of the Center from 1990 to 1993. At the Kennedy School, he became chair of the International and Global Affairs faculty and Ford Foundation Professor of Science and International Affairs. He concurrently was co-director of the Preventive Defense Project of Harvard and Universities. Early Department of Defense career.
Carter arrives in, in 2013 From 1993 to 1996, Carter served as during President Clinton's first term. He was responsible for strategic affairs, including dealing with the threat of weapons of mass destruction elsewhere in the world, nuclear weapons policy (including overseeing the U.S. Nuclear arsenal and missile defenses), the 1994, the signed in 1994 which froze North Korea's plutonium-producing program, the 1995 extension of the, the negotiation of the 1996, and the multibillion-dollar program and that removed all from, and. Carter directed military planning during the over 's nuclear weapons program. He was also responsible for dealing with the establishment of defense and intelligence relationships with former Soviet countries in the wake of the collapse of the Soviet Union and its nuclear arsenal, and was chairman of ’s High Level Group. He was also responsible for the Initiative, control of sensitive US exports, and negotiations that led to the deployment of Russian troops as part of the.
From April 2009 to October 2011, Carter was, with responsibility for DOD's procurement reform and innovation agenda and completion of procurements such as the tanker. He also led the development and production of thousands of mine-resistant ambush protected vehicles, and other acquisitions. He instituted 'Better Buying Power', seeking smarter and leaner purchasing.
From October 2011 to December 2013, Carter was, serving as the DOD’s, overseeing the department's annual budget and its three million civilian and military personnel, steering strategy and budget through sequester, and directing the reform of DOD's national security export controls. He was confirmed by Senate for both positions. In an April 4, 2013, speech, he affirmed that the 'Shift to Asia' initiative of President Obama was a priority that would not be affected by the. Carter noted that The Shift to Asia is principally an economic matter with new security implications. India, Australia, and New Zealand were mentioned as forthcoming security partners. His arms-control responsibilities included matters involving the, CFE, and other arms-control treaties.
Secretary of Defense. Carter (right) with General at (2016) Carter was nominated by President Obama to be the 25th on December 5, 2014. In his nomination hearing before the, he said he was “very much inclined” to increase U.S. Military aid to Ukraine. Speaking on the Middle East, he said the U.S. Must militarily ensure a “lasting defeat” of (ISIL) forces in and. He said he is not in favor of increasing the rate of prisoner releases from.
He also opined that the threats posed by were as serious as those posed by the ISIL forces. He was approved unanimously on February 1, 2015, by the Senate Armed Services Committee. He was confirmed by the Senate on February 12 by a vote of 93–5 and sworn in by Vice President on February 17.
In May 2015, Carter warned to halt its rapid island-building in the. In October 2015, Carter condemned air strikes against ISIL and other rebel groups in Syria. On October 8, 2015, Carter, speaking at a meeting of NATO defence ministers in Brussels, said he believed Russia would soon start paying the price for its in the form of reprisal attacks and casualties. A controversy arose in December 2015 when it was revealed that Carter had used a personal email account when conducting official business as Secretary of Defense.
In January 2016, at Carter's direction, the Department of Defense opened all military roles to women, overriding a request by the to continue to exempt women from certain positions. In June 2016, Carter announced that individuals would be allowed to join and openly serve in the military. Carter resigned one day before the end of the Obama administration. Other roles. Carter, William Perry and former Secretary of State, October 12, 2012 From 1990 to 1993, Carter was chairman of the Editorial Board of. Previously, he held positions at the Massachusetts Institute of Technology, the, and. In 1997, Carter and former CIA Director co-chaired the Catastrophic Terrorism Study Group which urged greater attention to terrorism.
In 1998 Carter, Deutch and (later executive director of the 9/11 Commission) published an article on “catastrophic terrorism” in Foreign Affairs. From 1998 to 2000, he was deputy to in the North Korea Policy Review and traveled with him to. In 2001–02, he served on the National Academy of Sciences Committee on Science and Technology for Countering Terrorism, and advised on the creation of the. Carter was also co-director of the Preventive Defense Project, which designs and promotes security policies aimed at preventing the emergence of major new threats to the US. Carter had been a longtime member of the and the, the principal advisory bodies to the Secretary of Defense. During the Bush administration, he was also a member of Secretary of State 's International Security Advisory Board; co-chair of the Senate Foreign Relations Committee's Policy Advisory Group; a consultant to the Defense Science Board; a member of the National Missile Defense White Team, and a member of the National Academy of Sciences Committee on International Security and Arms Control.
He has testified frequently before the armed services, foreign relations, and homeland security committees of both houses of Congress. In addition to his public service, Carter was a Senior Partner at Global Technology Partners, focused on advising investment firms in technology and defense. He has been a consultant to and on international affairs and technology matters, and speaks frequently to business and policy audiences. He was also a member of the boards of directors of the and and the advisory boards of and. Carter was also a member of the, the, the, the, and the. Carter was elected a fellow of the. He was named as a Fellow in the (Forum on Physics & Society) in 2015.
Carter departing from the Pentagon on his last day in office Carter was a supporter of the, as well as an advocate of 'preventative' invasions of and. In response to increase in tension in Ukraine, Carter considered proposing deployment of in Europe that could pre-emptively destroy Russian weapons.
Representative has criticized Obama's administration for its continued support for. On 2 March 2016, he sent a letter to Carter.
Lieu, who served in the U.S. Air Force, wrote in the letter that the 'apparent indiscriminate airstrikes on civilian targets in Yemen seem to suggest that either the coalition is grossly negligent in its targeting or is intentionally targeting innocent civilians.' Personal life Carter is married to Stephanie (DeLeeuw) Carter. He was previously married to the current and 8th, with whom he has two grown children, Ava and Will. Awards Carter received the award from the in 1987. For his service to national security, Carter has been awarded the DOD's highest civilian medal, the, five times.
For critical liaison efforts with the chairman of the and the geographic combatant commanders, he was awarded the in 2013. He also received the for his contributions to intelligence. Office of the Secretary of Defense - Historical Office. Cooper, Helene; Sanger, David E.; Landler, Mark (December 5, 2014). Retrieved February 5, 2015. Carter is a Democrat but not one of the core Obama loyalists, a group that includes Ms. Rice and Denis R.
McDonough, the White House chief of staff. Orlando Sentinel. August 2, 1994.
^ Sally Jacobs. Boston Globe. Philadelphia Daily News. Herb Drill (August 14, 1994).
Philadelphia Daily News. Retrieved December 8, 2014. Archived from on 2015-02-13. Archived from (PDF) on February 14, 2015. Retrieved 2015-02-13. FOX 29 News Philadelphia – WTXF-TV. December 3, 2014.
Archived from on February 13, 2015. December 11, 2014. Devin Dwyer. ^ Rebecca Shimoni Stoil, December 5, 2014.
Steve Straehley. ^. ^ Byron Tau. The Wall Street Journal.
Belfer Center. United States Department of Defense.
March 3, 2003. Retrieved June 9, 2009. Tom Sauer (2005). Carter, Ashton B. (September 2004). Retrieved December 2, 2014. ^, US House of Representatives Committee on Appropriations.
United States Department of Defense. September 30, 2013. Retrieved July 7, 2016. April 9, 2013.
Archived from on December 10, 2014. Retrieved December 2, 2014. Fox News Channel. December 5, 2014.
Retrieved December 5, 2014. Sara Fischer (December 5, 2014). Retrieved December 8, 2014. ^ Craig Whitlock (February 12, 2015). The Washington Post. Retrieved February 12, 2015.
^ Dion Nissenbaum (February 4, 2015). The Wall Street Journal. Hennigan (February 12, 2015). Los Angeles Times. David Lerman.
Emmarie Huetteman. The New York Times. Bill Chappell (February 17, 2015). May 27, 2015. The Guardian. October 8, 2015. The New York Times.
December 16, 2015. Cheryl Pellerin (December 3, 2015). Department of Defense. Department of Defense. June 30, 2016.
Washington Post. Retrieved 2017-07-13.
Carter, John Deutch, and Philip Zelikow: “Catastrophic Terrorism: Tackling the New Danger”, Foreign Affairs,. Office of the Under Secretary of Defense for Acquisition, Technology and Logistics.
Archived from on December 8, 2014. Retrieved December 8, 2014.
Crowley, Michael. Retrieved December 5, 2014. June 22, 2006. '. March 3, 2003.
December 24, 2003. '.
June 5, 2015. 17 March 2016. Atlantic Council. Retrieved 2017-07-13. External links Wikiquote has quotations related to: Wikimedia Commons has media related to. expert profile at the Belfer Center of Harvard University.
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