In selecting the basic parameters to be used for this project, the focus, WHOs current focus, would be on hospitalizations in 0 to 23-month-old children. Since there may be considerable variation in the threshold for hospitalization in different countries and since in some countries death may occur before arrival at hospital, this parameter by itself would not be adequate and would have to be supplemented with adequate definitions of pneumonia for use in evaluation of hospital databases. The use of a standardized set of definitions for pneumonia related to those used in efficacy trials would be very valuable in that they would provide a reliable estimate of the reduction of disease burden with the use of vaccine.
Radiological diagnosis of pneumonia
Currently, the best available method for diagnosing pneumonia is radiography. It is universally agreed that there exists at present no strict radiological definition of pneumonia in children. Instead, there is a spectrum of appearances that are consistent with the clinical and pathological diagnosis of pneumonia. At one end is the typical appearance of severe lobar consolidation, which is known to be strongly associated with bacterial pneumonia. At the other end are the mild interstitial and perihilar changes that are often associated with viral infections or asthma, and that may be part of the spectrum of normal appearances for children in developing countries. While the contribution of pneumococcus in those with lobar consolidation is known (see Table 1), its contribution to cases with these milder X-ray appearances is not as well recognized and will be an important finding in the current generation of vaccine trials.
Data from some of the etiological studies using lung aspirates along with the radiological findings in the children studied and the proportion in whom any bacteria or pneumococcus was detected are summarized in Table 1. Table 1. Summary of radiological findings and bacterial isolation rates from lung aspirates in children with pneumonia.
Author (ref) Site N Radiological criteria % bacterial* 45.1 (56.8) 28 61.4 51.3 (60) 53 (50) 37.1 49.1 82.54.2 (73.9) 20 40.6 53.6 15.9 8.2 % pneumococcal 34 25.7 9

Mimica (12) Mimica (12) Shann (13) Kalra (14) Cunanan (15)
Chile Chile PNG India Philippines
Bronchopneumonia (pleural effusion and lobar consolidation excluded) Lobar consolidation Consolidation away from hilum Consolidation Confluent densities, consolidation, fluid or air in pleural space, pneumatocoele, abscess (bronchopneumonia 43%, effusion 37%, lobar pneumonia 16%) Lobar consolidation (6 with empyema) Lobar consolidation Consolidation adjacent to chest wall (malnourished) Consolidation adjacent to chest wall (well nourished) Lobar consolidation or effusion Bronchopneumonia (ill-defined infiltrates) Consolidation
Falade (16) Wall (17) Adegbola (18) Adegbola (18) Silverman (19) Silverman (19) Diakparomre (20)
Gambia Gambia Gambia Gambia Nigeria Nigeria Nigeria
Figure in parentheses indicates the percentage of patients without prior antimicrobial treatment who had positive culture.
Though some degree of alveolar consolidation is necessary for lung aspirates, there were a few studies where aspirates were obtained even in children without lobar consolidation. In two studies, one from Chile (12) and the other from Nigeria (19) the authors clearly differentiated between lobar consolidation and other infiltrates (termed as bronchopneumonia). In these studies, bacteria were isolated from 45% and 84%, respectively, of children with bronchopneumonia though pneumococci formed only a small proportion of the isolates. In another study from the Philippines a majority of patients had bronchopneumonia (which was defined as diffuse alveolar infiltrates) but the bacteriological results from these patients were not presented separately from those with lobar pneumonia. In this study also, while overall isolation rates of bacteria were high, pneumococcus was isolated in only a small proportion. In contrast, in most of the studies where patients had lobar
consolidation, the predominant bacterial pathogen was S. pneumoniae, especially in well-nourished children; in malnourished children mycobacteria were often detected (18). These data suggest that the radiological manifestation most likely to be associated with pneumococcal infection is lobar consolidation; the presence of other types of infiltrates may also suggest bacterial etiology in a sizeable proportion of cases but is usually due to bacteria other than pneumococcus. However, a proportion of these, albeit small, are also caused by pneumococcus. Since the number of children who have infiltrates other than lobar consolidation is likely to be substantially higher than those with lobar consolidation, this small proportion may add up to a sizeable number of cases prevented by vaccination. Therefore, though pneumonia with lobar consolidation may remain as the primary end-point of interest inasmuch as it represents pneumonia most likely to be due to pneumococcus, it would be important to count cases with other pulmonary infiltrates. In most of the studies cited above, there was no clear description of the radiological findings and there does not appear to have been a standardized interpretation of the radiographs. Therefore, no definite conclusions can be drawn from these studies. This makes it difficult to apply the results of these studies to define clear end-points for vaccine trials and has been one of the difficulties in comparing the results from many of the reported studies. It is a problem that must be addressed in future studies. An additional problem in certain sites would be the increasing prevalence of HIV infection in the study population. Pneumococcal pneumonia in HIV-infected individuals may have an atypical presentation, with multilobar distribution of pathology being more common (21). On the other hand, opportunistic infections, such as P. carinii pneumonia, which are common in this population may produce radiological changes that are similar to those associated with pneumococcal pneumonia (19). In areas with high prevalence of HIV this may lead to errors in estimation of vaccine efficacy when the definitions that are based on radiological end-points do not take into consideration the HIV status of the patient. In the context of a vaccine trial, an end-point comprising only cases with severe changes offers the best prospect of showing an impact of the vaccine. However numbers will be small in some settings, limiting power, and such an analysis may seriously underestimate the vaccine-preventable burden of disease by excluding many cases of pneumococcal pneumonia. At the other end of the spectrum noise due to the many mild, mostly viral infections means that the differences between vaccine and control groups might be small and not statistically significant. However, between these two ends of the spectrum are other categories that may represent bacterial pneumonia preventable by vaccines. Therefore, it will be necessary to identify and count other categories of changes seen on X-ray that may potentially be affected by vaccination.

Observer variation in interpretation of chest radiographs in pneumonia
Previous experience suggests that there may be considerable variation in interpretation of chest radiographs by clinicians as well as radiologists. (22,23) However, there are relatively few studies that have critically looked at this issue. It is heartening to note that in these studies agreement for the presence or absence of consolidation or the presence of or absence of infiltrates was high. However, there was significant disagreement about minor changes and in the description of the infiltrates. Since the level of training and the understanding of the terminology used for describing radiological changes may vary considerably between study sites in different countries, it is absolutely essential to agree on the descriptive terminology to be used and to standardize the interpretation of radiographs across study sites. The focus of this exercise will be to define criteria for the interpretation of chest radiographs from study subjects for the purposes of vaccine trial endpoint definition and for disease burden studies and to determine inter and intraobserver variation in interpretation while using these standardized criteria. This aspect of the studies is important, as the diagnosis of pneumonia is either a primary or co-primary endpoint in most pneumococcal vaccine trials to date and in some of the Hib vaccine trials being conducted in Asia. The criteria will be developed, standardized and validated using material obtained from these sites and then offered for use in these and other trials as well as in the generic protocol developed to determine pneumonia disease burden once again. It should be emphasized that the standards and definitions described in this document are meant as an epidemiological tool and may not always apply for patient care.

Objectives

1) 2) 3)
To establish standard definitions for the interpretation of chest radiographs in children with suspected pneumonia for use as an epidemiological tool. To establish a mechanism for ensuring the quality of radiographic images stored in digital format. To determine inter and intra-observer variation in interpretation of a standard reference panel of chest radiographs compiled and coded by a WHO radiologist reference panel, using standard definitions. To establish a mechanism for central reference reading to maintain uniformity in interpretation of chest radiographs at the study sites and to resolve discordant readings and maintain ongoing quality control. To establish a standardized training software for interpretation of chest radiographs for the diagnosis of pneumonia for use at newer vaccine trial sites and by those carrying out disease burden studies of pneumonia or evaluating the efficacy of various intervention in reducing the pneumonia disease burden.

Image quality and interpretation of the images
Optimal interpretation of a chest radiograph will depend on the quality of the image and the methods used to interpret the image. Since interpretation will mainly be performed on digitized images, the quality of the image being interpreted will depend on the quality of the original image (the radiograph) as well as the quality of the digitization process. In addition the monitor and the setting of the monitor used to view the digitized images are crucial for optimal interpretation.
Quality of the original radiograph
A readable X-ray is crucial for the diagnosis of radiological pneumonia. There is a risk that in the sickest patients, films that are taken with poor positioning and with portable machines are more likely to be unreadable, leading to a systematic bias. X-ray procedures and processing of films must be optimized to ensure that the best possible quality films are produced. In particular, proper attention needs to be paid to positioning and collimation, which appear to be the primary reason for unreadable films. In addition X-ray safety must be optimized to minimize radiation exposure. It is recommended that radiologists at the study sites closely interact with radiographers and technicians, stressing the importance of film quality as well as adequate radiation protection measures. This is to ensure that the proportion of uninterpretable and suboptimal films are kept to a minimum, and that radiation exposure for patients as well as staff members and/or other people is kept as low as possible, and according to national and international laws and regulations. Initial training workshops for all radiographers involved in the trial, with periodic reinforcement would be one way of achieving this. When the initial radiograph is unsatisfactory for the purposes of treating the patient, the treating physician may authorize a repeat radiograph. A few suggested guidelines for checking film quality are as follows: 1) 2) Exposure are you able to discern the bones, soft tissue and lungs as different densities? Development is there complete blackening of the film outside the body on the edge of the film (where the X-rays have passed through air) and maintaining whiteness in the very dense areas such as the lower thoracic spine behind the heart? If the film outside the body were hazy or mottled, shadows within the lung would be difficult to interpret. Positioning are the medial ends of the clavicles approximately equidistant from the midline?
A copy of the checklist used in Lombok, Indonesia for determining film quality is given in Annex 1. The American College of Radiology standard for obtaining paediatric chest radiographs is available at www.acr.org.
Are lateral films necessary?
Though certain sites may take lateral films routinely for all cases of suspected pneumonia other sites do not. Only frontal films (AP or PA views) will be mandatory at all sites. Sites where lateral films are taken routinely may continue to do so. Studies have shown that lateral films added to the information available in frontal films in only a few instances and that limiting lateral films to those patients where a there was a specific indication is a reasonable option. (26,27)

Digitization of radiographic images
Where conventional (analogue) X-ray machines are used for obtaining images, these will need to be converted to digital images. Members of this group have experimented with a number of systems. Based on their experience, the following methods will be used at the various sites: Purpose-built X-ray scanning machines the CCD film digitizers provide results that are equivalent to laser scanners but are they less expensive. Most of the current study sites are proposing to use CCD scanners. This method is recommended (budget permitting) for sites that have not yet decided on which method to use. The listed price for the cheapest CCD scanner is approximately US$ 10 000. Cheaper prices may be negotiated with the company if several study groups place a joint order. Details for the Vidar scanner being used by several sites is available on the Internet at: http://www.filmdigitiser.com. Simple flat bed scanner this method was evaluated at a few sites. The image quality is not as good as the one obtained with a CCD scanner. This requires the use of a transparency adapter along with a flat bed scanner. The procedure that was used in Lombok is given in Annex 2. Hand held digital camera this method has been evaluated in Chile. Careful attention has to be paid to the type of camera used, the illumination source and the camera settings for getting a suitable image. Practical tips on getting the best images while using digital cameras have been published (28) and those planning to use this method should read this paper to optimize the images. The details of the procedure used in Chile are given in Annex 3. Even with all the modifications, there is some loss of image quality and definition of shadows that constitute other infiltrates may not be optimal.
The American College of Radiology standards for digital image management are available at their web site: www.acr.org.
Maintaining quality of digitized images
During the calibration workshop where original films and the corresponding digitized images were viewed, it was clear that the method of digitization and the settings of the digitizer could affect the quality of the image produced and a mechanism to assure quality of the digitized images are required. The following methods will be used to maintain quality of the digitized images: 1) Use of a standard test pattern which could be used along with every batch of films scanned to assure quality. A special software distributed by Vidar called the Assure Quality Control Software would be suitable for this purpose. Details of this software are available at the companys web site: www.filmdigitiser.com. This program may be particularly useful in sites using the CCD scanners to assure themselves that their scanner settings and techniques were optimal. The quality assurance package could even be run with every batch of films scanned. Since the image quality as decided by the above software may not be necessary for interpreting radiographs for study purposes, it may be useful to use a standard set of chest radiographs with delineation of what findings should be clearly visible in the digitized version of the radiograph. A standard set of paediatric chest radiographs and the features that require to be delineated in the digitized image will be distributed to the study sites. These films could be scanned periodically to check the quality of the digitization process.

It is proposed that lower precision would be acceptable for estimating intra-observer agreement than for inter-observer agreement, and that an acceptable practical value would be to repeat the readings on half the films, i.e. n=100. See the Table for resulting precision values.
Mechanics of readings for intra-observer agreement
It is proposed that the 200 test panel films be sent (Day1), read, and results returned, and that these be followed in a week (Day 8) by a random selection, randomly re-ordered, of 100 of these films, to be read independently without any reference back to the readings for the original set.

Training software

Concurrently with the calibration and standardization exercises, training software for the interpretation of films will be created. This software will serve in training new sites or groups undertaking studies on childhood pneumonia in interpretation of chest radiographs. The software may also be used for ongoing quality assessment of readers at the study sites. The software will consist of a repository of films which describe the spectrum of radiological changes seen in children with suspected pneumonia, including sets of normal films and unreadable films. This will be combined with appropriate software to view the films, to read text describing the abnormalities seen in each of the films, to manage the film repository and for self-assessment. This software will be prepared in collaboration with a commercial company specialized in the preparation of training software in radiology. Ideally, this software should be distributed at the beginning of each study. However, since many of the studies are already under way or are nearing completion, preparation of this software will run concurrently with the calibration and standardization exercise. It is anticipated that this software will be useful in training those interpreting X-rays in future intervention studies or disease burden studies of bacterial pneumonia.

Bibliography

Programme for control of acute respiratory infections. Interim programme report. Geneva, World Health Organization, 1991, (unpublished document WHO/ARI/91.19; available from Child and Adolescent Health and Development, World Health Organization, 1211 Geneva 27, Switzerland). Berman S. Epidemiology of acute respiratory infections in children of developing countries. Reviews of Infectious Diseases, 1991, 13 (Suppl 6):S45462. Acute respiratory infections in children case management in small hospitals in developing countries: a manual for doctors and other senior health workers. Geneva, World Health Organization 1990, (unpublished document WHO/ARI/90.5; available from Child and Adolescent Health and Development, World Health Organization, 1211 Geneva 27, Switzerland). Sazawal S, Black RE. Metaanalysis of intervention trials on case-management of pneumonia in community settings. Lancet, 1992, 340:52833. Invasive Bacterial Infection Surveillance (IBIS) Group. Prospective multicentre hospital surveillance of Streptococcus pneumoniae disease in India. Lancet, 1999, 353:121621. Strauss WL et al. Antibiotic resistance and the clinical effectiveness of co-trimoxazole versus amoxycillin for pneumonia among children in Pakistan: a randomized clinical trial. Lancet, 1998, 352:2704. Mulholland K et al. Randomised trial of Haemophilus influenzae type b tetanus protein conjugate vaccine for prevention of pneumonia and meningitis in Gambian children. Lancet, 1997, 349:11917. Levine OS et al. Defining the burden of pneumonia in children preventable by vaccination against Haemophilus influenzae type b. Pediatric Infectious Disease Journal, 1999 Dec, 18(12):10604. Black S et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Pediatric Infectious Disease Journal, 2000, 19:18795. Shinefield HR, Black S. Efficacy of pneumococcal conjugate vaccines in large-scale field trials. Pediatric Infectious Disease Journal, 2000, 19:3947. Mulholland K et al. Evaluation of vaccines for the prevention of pneumonia in children in developing countries. Epidemiological Reviews, 1999, 21:4355. Mimica I et al. Lung puncture in the etiological diagnosis of pneumonia. American Journal of Diseases in Children, 1971, 122:27882.

Image area is confined to the rib cage and includes both costophrenic angles. 4) Inspiration Y N
Dome of the diaphragm is below the 8th rib. 5) Movement Y N
The heart, diaphragm, large pulmonary vessels and ribs are sharply defined without blurring. 6) Exposure I Y N
Vascular shadows can be seen in the lung periphery. 7) Exposure II Y N
Large lower lobe vessels and the thoracic vertebrae are visible through the cardiac silhouette. 8) Contrast Y N
Background outside of patients silhouette is black, not grey. Bones and airways should be easily distinguished from soft tissue.

Annex 2:

Procedure for scanning with UMAX Astra 2400S scanner, with transparency adapter (Steinoff 1999)
1) Before scanning Orient film so heart shadow is mostly on the left side of film (viewers right), and R marker is on the right side of the film (viewers left). Apply 2.5 cm. marker to film, outside of ribcage, below diaphragm. Use black marker to write study form number on film, near 2.5 cm marker. Place film face down on scanner bed and close cover. 2) 3) 4) Use the VISTA scan software: Go to advanced menu Then select the following from the menu: 5) 6) 7) 8) 9) UTA transmissive B/W photo 300 dpi no descreen no filter 50% size auto adjustment
Do preview scan of film Adjust image margins to include rib cage only Do another preview scan (to allow auto exposure for new size image) Do full scan Save file as GIF format, or as JPEG at 80% compression, using Hib form number as file name

Annex 3:

Procedure for converting X-rays into digital images using a digital camera (Lagos R, Chile)

Equipment:

1) 2) Camera: Agfa 1680 or Mavica FD90. White-light screen with two switches and four 10-Watts tubes. Two tubes on are enough for most films, but 4 might be necessary for dark films. Monitor: SVGA, 17". Resolution must be similar to the resolution of the image

Capturing the image:

1) 2) Set the camera at a resolution of 1024 x 768 or higher. Place the film on with cardboard strips. the screen and cover the empty edges
Adjust the distance manually (digital zoom off), so that the image is properly centred on the LCD. Shoot. JPEG file: download the image from the camera to the computer using lowest possible compression. Convert to greyscale.

Annex 4:

Chest radiograph interpretation document, for WHO trialists group
Goal: to offer instruction sufficient for radiologists and non-radiologists to consistently interpret frontal chest radiographs in terms of the presence or absence of findings likely to be associated with bacterial pneumonia. Caveats: some of the radiographs will be normal. Many of the radiographs will be abnormal, because the patient has viral pathology. There is a great deal of overlap in the radiographic appearance of viral and bacterial disease. The challenge will be to maximize the number of true positives, without including too many false positives. Film artefacts: films that are very light or that are blurry will appear more abnormal than they actually are. Normal markings will be accentuated by light X-ray technique and by outdated developer, and blurry normal markings will look like infiltrates. Definitions of terms: for the purposes of this study. (See also accompanying diagrams) 1) 2) 3) 4) 5) 6) 7) Infiltrate: any pathologic density in the lung. Alveoli: tiny air-filled spaces where oxygen and C02 are exchanged (see diagram B) Bronchi: tubes leading from the trachea to the alveoli Interstitium (adi: interstitial): lung tissue outside the air-containing spaces: includes support tissues, blood vessels, bronchial walls, lymphatics Alveolar infiltrate: alveoli filled with fluid (pus, oedema, etc.) Heart and diaphragm borders: see accompanying diagram A. Air bronchogram: branching linear lucent structure representing air still present in bronchi after the alveoli around them have consolidated; not to be confused with peribronchial thickening (an interstitial infiltrate) Consolidation: especially dense, often homogeneous, confluent alveolar infiltrate sometimes may encompass an entire lobe or large segment, fluffy, mass-like, cloud-like density, erases heart and diaphragm borders (silhouette sign); often contains air bronchograms Atelectasis: volume loss as air is absorbed from lung tissue, usually distal to an airway obstruction (e.g. a mucous plug). The lung tissue collapses like a Japanese fan, leaving a dense streak on the film that radiates outward from the hilum. (sec diagram D) Interstitial infiltrate: includes peribronchial thickening and tiny areas of atelectasis (thought to be typical of viral infection).

Pleural effusion: fluid collecting in the pleural space around the lung, seen as a dense rim (the same density as the chest-wall muscles) interposed between the lung and the ribs (diagram C) Peribronchial thickening or cuffing: increased density of the walls of the smaller bronchi (away from the immediate hilar area) so that they become visible as circles or parallel lines (diagram E)
Definitions of study end-points: Quality
1) Uninterpretable: an image is classified as uninterpretable if the features of the image are not interpretable in terms of presence or absence of primary end-point without additional images. No further reading should be made for such images. Suboptimal: an image is classified as suboptimal if the features allow interpretation of primary end-point but not of other infiltrates or findings. No entries should be made for other infiltrates for such images. Adequate: an image is classified as adequate if the features allow confident interpretation of end-point as well as other infiltrates.
Classification of findings
1) Significant pathology: this refers specifically to the presence of consolidation, infiltrates or effusion. If none of these are present then no further reading or recording is required for that film. End-point consolidation: a dense opacity that may be a fluffy consolidation of a portion or whole of a lobe or of the entire lung, often containing air bronchograms and sometimes associated with pleural effusion.1 Other (non-end-point) infiltrate: linear and patchy densities (interstitial infiltrate) in a lacy pattern involving both lungs, featuring peribronchial thickening and multiple areas of atelectasis. Lung inflation is normal to increased. It also includes minor patchy infiltrates that are not of sufficient magnitude to constitute primary end-point consolidation, and small areas of atelectasis which in children can be difficult to distinguish from consolidation. Pleural effusion: this refers to the presence of fluid in the pleural space between the lung and chest wall. In most cases this will be seen at the costo-phrenic angle or as a layer of fluid adjacent to the lateral chest wall. This does not include fluid seen in the horizontal or oblique fissures. Pleural effusion is considered as primary end-point if it is in the lateral pleural space (and not just in the minor or oblique fissure) and is spatially associated with a pulmonary parenchymal infiltrate (including other infiltrate) OR if the effusion obliterates enough of the hemithorax to obscure an opacity.

Atelectasis of an entire lobe that produces a dense opacity and a positive silhouette sign with the mediastinal border will be considered to be an end point consolidation.

Conclusions

1) Primary end-point consolidation or pleural effusion: the presence of end-point consolidation (as defined above) or pleural effusion that meets criteria for primary end-point (as defined above). Other consolidation/infiltrate: the presence of other (non-end-point) infiltrate as defined above in the absence of a pleural effusion. No consolidation/infiltrate/effusion: absence of end point consolidation, other infiltrate or pleural effusion. Diagrams
Diagram A: Borders and what they mean
1. Right diaphragm erased by a right lower lobe infiltrate. 2. Right heart (right atrium) erased by a right middle lobe infiltrate. 3. Minor fissure divides the right upper lobe from the right middle lobe; seen as a line when there is fluid in it; seen as a border when there is infiltrate in the lobe adjacent to it. 4. Left heart (left ventricle) erased by an infiltrate in the lingula (homolog of the right middle lobe; actually a part of the left upper lobe). 5. Left diaphragm erased by an infiltrate in the left lower lobe, often behind the heart shadow. 6 and 7. Right hilum and left hilum contain large blood vessels, lymph nodes, and main bronchi; bronchial walls may be normally visible here, but should disappear quickly just outside the immediate hilar area. 8. Thymus bi-lobed semi-lucent structure in the upper mid chest with defined borders, may resemble an upper lobe infiltrate but often shrinks when the child is sick. 9. Heart from the spine to the left heart border should be the same density.
Diagram B: Air-space anatomy trachea
Diagram C: Pleural fluid accumulation pleura
bronchi ribs alveoli lung

Diagram D: Atelectasis

Diagram E: Peribronchial thickening or cuffing bronchus in cross-section

bronchus from the side

Annex 5:
Data recording instrument
A spreadsheet in Microsoft Excel has been developed for data entry for the purposes of calibration and standardisation of films. It consists of the following fields: Study site: Reader ID: Date of reading: X-ray ID: Is the film quality adequate? a. s. u. Adequate Suboptimal Unreadable
Does the film contain significant pathology? Yes/no Primary end-point consolidation? Other consolidation/infiltrate? Pleural fluid? Right Right Right Yes/No Yes/No Yes/No Left Left Left Yes/No Yes/No Yes/No

Conclusion

1) 2) 3) Primary end-point consolidation or pleural effusion Other consolidation/infiltrate No consolidation/infiltrate/effusion

Notes:

The findings may be entered using the definitions given in Annex 4 and the notes for entering data into the spreadsheet (given below). The entry for conclusion will be logically constrained by the answers to the other questions. For example, if Does the film contain significant pathology? is no, then the conclusion will be obliged to be no consolidation/infiltrate/effusion. Also if Primary end-point consolidation? is yes, then the conclusion must to be Primary end-point pneumonia. If Other infiltrate/abnormality? and Pleural effusion? are yes, the conclusion will have to be Primary end-point pneumonia. If the answers to Pleural effusion? alone are yes and Primary end-point consolidation? and Other infiltrate/abnormality? are no, the conclusion will
be Other infiltrate/abnormality. If answers to Other infiltrate/abnormality? are yes and all others are no, the conclusion will be Other infiltrate/ abnormality. If the answers to all, Primary end-point consolidation?, Other infiltrate/abnormality? and Pleural effusion?, are no, then the conclusion must be No consolidation/infiltrate/effusion. These answers will be automatically entered, based on responses to earlier questions. Notes for using the Excel spreadsheet X-ray.xls: 1) The original file X-ray.xls itself should not be used for data entry. Data should be entered into a copy of this file, which can be named appropriately for your site (e.g. X-ray_aus1.xls). A new copy of a file can be made very simply using the Windows Explorer, or you can open the original file in Excel and make a new copy immediately by using the Save As dialog on the File menu. (Please seek help if you are not familiar with these Windows operations.) The worksheet has been programmed to take 500 rows of data. To enter data for more than 500 films, you will need to make a new copy of the spreadsheet file and start afresh. Some of the columns have dropdown boxes containing valid options. The valid options for Quality (column E) are a, s and u while the valid options for Significant Pathology to Pleural fluid_R (columns F to L) are yes and no. Note that once a value has been entered in a column, there is no need to type in the entire word again. For instance, if yes has previously been entered in column F, entering only y in that column (followed by Tab or Enter) is sufficient. If you enter u for quality, no further entries are required for that image. If you enter s for quality, do not record any findings for other infiltrates since by definition a suboptimal film does not allow interpretation of other infiltrates. When no is entered in Significant Pathology (column F), Primary cons_L to Pleural fluid_R (columns G to L) are automatically filled in with no. Conclusion and Flag (columns M and N) are locked so that nothing can be entered in either of these columns. The entire worksheet is also protected so that formatting changes cannot be made. Conclusion (column M) is updated automatically as per the definition above. Flag (column N) will show the word ERROR in red under the following circumstances: If Significant Pathology is yes and Primary cons_L to Pleural fluid_R are all no. If Significant Pathology is no and at least one of Primary cons_L to Pleural fluid_R is yes. If a value for Conclusion is displayed and at least one of the columns from Date to Pleural fluid_R (columns C to L) is blank. Note that ERROR will appear in the Flag column as soon as the value for Conclusion is displayed if at least one of the columns from C to L of that record are blank. Once all of these cells have been filled, the word ERROR will vanish, assuming there are no other inconsistencies.

Annex 6:

Radiology Working Group
Dr Aliu O. Akano, National Hospital, Department of Radiodiagnosis, Central District (Phase II), Garki, Abuja, Nigeria Tel.: +2342686 Ext. 2557 or 2785; Fax: +2342632 Email: aakano@hotmail.com Prof. Ruhul Amin, Professor of Pediatrics, Bangladesh Institute of Child Health, Dhaka Shishu (Childrens) Hospital, Sher-e-Bangla Nagar, Bangladesh Tel.: +8111 556; Fax: +308 Email: ruhula@bdcom.com Dr Abdullah Hel Baqui, International Centre for Diarrhoeal Disease Research, Bangladesh, ICDDR,B GPO Box 128, Dhaka 1000, Bangladesh Tel: 871751; Fax: +883116 Email: ahbaqui@citecho.net Prof. Jacob Bar-Ziv, Hadassah Medical Organization, Department of Radiology, Kiryat Hadassah, IL 91120 Jerusalem, Israel Tel.: +677 6901; Fax: +Dr Jane Benson, Assistant Professor, Radiology, Johns Hopkins Hospital, Radiology Department, 615 N. Wolfe Street, Baltimore, MD 21205, USA Tel.: +955 6140; Fax: +Email: jebenson@rad.jhu.edu Dr Margaret de Campo, Murdoch Childrens Research Institute & University of Melbourne, Clinical Epidemiology and Biostatistics Unit, Royal Childrens Hospital, Melbourne, Victoria 3205, Australia Tel.: +Email: decampom@cryptic.rch.unimelb.edu.au Dr John Carlin, Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute & University of Melbourne, Department of Paediatrics, Royal Childrens Hospital, Parkville, Victoria 3052, Australia Tel.: +9345 6362; Fax +Email: jbcarlin@unimelb.edu.au Dr Ron Dagan, Director, Soroka Medical Center, Pediatric Infectious Disease Unit, P.O. Box 151, Beer Sheva 84101, Israel Tel.: +47; Fax: +Email: rdagan@bgumail.bgu.ac.il
Dr Bradford Gessner, Chief Epidemiology, AMP Institut Pasteur, 9740 Hillside, Anchorage, AK 99516, USA Dr David Greenberg, Soroka Medical Center, Pediatric Infectious Disease Unit, P.O. Box 151, Beer Sheva 84101, Israel 84101 Tel.: +640 0547; Fax: +Email. dudi@bgumail.bgu.ac.il Dr Brian Greenwood, London School of Hygiene and Tropical Medicine, Department of Infectious and Tropical Diseases, 50 Bedford Square, GB-London WC1B 3DP, United Kingdom Tel.: +47 07; Fax: +Email: b.greenwood@lshtm.ac.uk Dr Zahid Hossain, Assistant Professor of Radiology, Bangladesh Institute of Child Health, Dhaka Shishu (Childrens) Hospital, Sher-e-Bangla Nagar, Bangladesh Tel.: +911 7834; Fax: +9128308 Email: bich@bdcom.com Prof. Keith Klugman, Professor of Infectious Diseases, Department of International Health, The Rollins School of Public Health, Emory University, 1518 Clifton Road, N.E, Room 764, Atlanta, GA 30322, USA Tel.: +712 9001; Fax: +Email: kklugma@sph.emory.edu Dr Rosanna Lagos, Hospital Roberto del Rio, Centro para Vacunas en Desarollo, Servicio de Salud Metropolitano Norte, Avda. Zanartu 1085 (Cuarto Piso), Santiago, Chile Tel.: +737 5022; Fax: +5766 Email: cvdchile@netup.cl Dr Marilla Lucero, Research Institute for Tropical Medicine, DOH Compound, Alabang, Metro Manila, Philippines Tel.: +807 2634; Fax: +Email: mglucero@pacific.net.ph Dr Socorro Lupisan, Research Institute for Tropical Medicine, DOH Compound, Alabang, Metro Manila, Philippines Tel.: +807 2634; Fax: +Email: philari@pworld.net.ph Dr Shabir Mahdi, Pneumococcal Diseases Research Unit, SAIMR Room 11, Chris Hani-Baragwanath Hospital, P.O. Box Bertsham, Diepkloof, Soweto 2013, South Africa Tel.: +489 8786; Fax: +Email: shabirm@mail.saimr.wits.ac.za Dr Jack Marvis, Pneumococcal Diseases Research Unit, SAIMR Room 11, Chris Hani-Baragwanath Hospital, P.O. Box Bertsham, Diepkloof, Soweto 2013, South Africa Tel.: +(H); Fax: +489 8692

Dr Karla Moene, Hospital Roberto del Rio, Centro para Vacunas en Desarollo, Avenida Zanartu 1085, Cuarto Piso, Independencia, Santiago, Chile Tel.: +735 7263; Fax: +Prof. Kim Mulholland, Royal Childrens Hospital, Department of Pediatrics, Flemington Road, Parkville, Victoria 3051, Australia Tel.: +345 5161; Fax: +Email: mulhollk@cryptic.rch.unimelb.edu.au Dr Alma Munoz, Hospital Roberto del Rio, Centro par Vacunas en Desarollo, Avenida Zanartu 1085, Cuarto Piso, Independencia, Santiago, Chile Tel.: +735 7263; Fax: +Email: cvdchile@netup.cl Dr Awaatief Musson, South African Institute for Medical Research (SAIMR), Hospital Street, P.O Box 1038, Johannesburg 2000, South Africa Tel.: +489 9010; Fax: +Email: redc@icon.co.za; redc@michelin.co.za Dr Hanna Nohynek, Senior Scientist, KTL National Public Health Institute, Department of Vaccines, Mannerheimintie 166, FIN-00300 Helsinki, Finland Tel.: +4744 8246; Fax: +Email: hanna.nohynek@ktl.fi Dr Terry Nolan, University of Melbourne, Department of Pediatrics, 4th Floor, Front Building, Royal Childrens Hospital, Parkville, Victoria 3052, Australia Dr Katherine L. OBrien, Johns Hopkins University, The Center for American Indian and Alaskan Native Health, 621 North Washington Street, Baltimore, MD 21205, USA Tel.: +614 3806; Fax: +Email: klobrien@jhsph.edu Dr Steven K. Obaro, Station Head, Medical Research Council Laboratories, P.O. Box 273, Fajara, The Gambia Tel.: +462; Fax: +626 Email: sobaro@gamtel.gm Dr Vicente V. Romano, Jr., Research Institute for Tropical Medicine, DOH Compound, Alabang, Metro Manila, Philippines Tel.: +837 1814; Fax: +Email: vic_ester@pacific.net.ph Dr Mathuram Santosham, Johns Hopkins School of Hygiene and Public Health, Center for American Indian Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Tel.: +955 6931; Fax: +Email: msantosh@jhsph.edu
Prof. Mark Steinhoff, Johns Hopkins School of Public Health, Department of International Health, Hygiene 3505, Division of Disease Control, 615 N. Wolfe Street, Baltimore, MD 21205, USA Tel.: +955 1623; Fax: +Email: msteinho@jhsph.edu Prof. Heinz Tschppeler, Institut fr Diagnostische Radiologie, Departement Radiologie, Neuroradiologie, Inselspital Hpital de lIsle, CH-3010 Bern, Switzerland Tel.: +632 9502/01; Fax: +Email: heinz.tschaeppeler@insel.ch

WHO Secretariat

20 avenue Appia, CH-1211 Geneva 27, Switzerland Dr Thomas Cherian, Vaccine Development, Department of Vaccines and Biologicals Tel.: +791 4460; Fax: +Email: cheriant@who.int Dr Harald Ostensen, Department of Blood Safety and Clinical Technology Email: ostensenh@who.int

Lockheed Martin Space Systems Company, Michoud Operations is offering for sale by sealed bid a wide variety of Federal personal property stored at the Michoud Assembly Facility, New Orleans, La. 70l29. This is your invitation for Bid. It contains descriptions of the property by lot number, sale terms, and a bid form. Bid amount is required by single lots which will include all items within that lot. You may bid on any one lot or all lots individually. SEALED BID SALE: 0268-S1901A BID CLOSE DATE: December 15, 2008: 2:00 PM PROPERTY CAN BE INSPECTED FROM 8:00 AM TO 3:00 PM December 1-5, 2008 and December 8-11, 2008. Lockheed Martin Michoud Operations 13800 Old Gentilly Road New Orleans, La. 70l29 Point of Contact: Warren Wilson Property Disposal Representative 504-257-1708 or 257-1709 e mail Warren.E.Wilson@maf.nasa.gov DEFENSE FEDERAL ACQUISITION REGULATIONS Mandatory terms and conditions clauses 245.7309 - 245.7309.7 AND 245.7309.10 - 245.7309.14 apply. Standard Form 114C clause 24 prescribed by GSA FPMR (41CFR)101-45-3) applies. Results will be available after 5 business days following bid closing. They can be accessed via the internet at the Lockheed Martin Michoud Operations External web page or by contacting the Property Disposal Representative listed above. http://www.lockheedmartin.com/ssc/michoud/products/SurplusSales.html REMOVAL OF PROPERTY MUST BE ACCOMPLISHED WITHIN TEN (10) DAYS FROM ASSIGNED REMOVAL DATE SPECIFIED IN THE NOTIFICATION OF SUCCESSFUL BID AWARD DOCUMENT. Property purchased in this sale cannot be brought back into the NASA Michoud Assembly Facility.
Lot # 01 Battery Tester (1 ea.) (Dayton 3Z634A), Tricycle (7 ea.) (Workman U), Battery Tester (1 ea.) (Dayton 4Z581C) USED Lot # 02 Drill Motor (1 ea.) (Thor EJ3-750RPM), Drill Motor (1 ea.) (Rockwell 756), Drill Motor (1 ea.) (Thor E100), Drill Motor (1 ea.) (Ingersol-Rand 7803R), Grinder (1 ea.) (Skil 959), Diamond Core Drill (1 ea.) (Milwaukee D-214), Sander (1 ea.) (Thor EN89-550rpm), Sander (1 ea.) (Skil 495), Angle Drill Motor (1 ea.) (Black & Decker 746-450RPM), Disc. Grinder (1 ea.) (Skil 852), Nibbler (1 ea.) (Black & Decker 691-NO8), Air Shear (1 ea.) (Florida FP-6001), Shear (1 ea.) (Kett E140), Saw (1 ea. ) Skil 825), Jig Saw (1 ea.) (Skil 160), Heavy Duty Jig Saw (1 ea.) Black & Decker 3155 Type 1), Torque Wrench (2 ea.) (General Instruments TS-100), Drill Motor (1 ea.) (Black & Decker 361-450 RPM), Electric Wood Plane (1 ea.) (Skil 100 Type 3), Mitre Saw (1 ea.) Ryobi America Corp. TS-254), 14 Chop Saw (2 ea.) (Black & Decker 2730), Air Grinder (1 ea.) (Dynabrade RPM), Make-UP Kit (3 ea.) (Greenlee 1910) USED Lot # 03 Color Monitor (1 ea.) (Micron Electronics MNN001044-01), Scanner (1 ea.) (UMAX ASTRA 2400S), Tachometer (1 ea.) (SPM Instrument TAC-10), Handheld Calibrator (1 ea.) (Rosemount Inc.), Handheld Interface (1 ea.) (Rosemount 268), Communicator (3 ea.) (Fisher-Rosemont 275), Hygrometer (1 ea.) (Beckman 9613), Voltage Calibrator (1 ea.) (Extech Instruments 412355), Compas (2 ea.) (SUUNTO 8025-10), Moisture Meter (2 ea.) (Omega HHMM690), Fiber Optic Nanameter (1 ea.) (Darkstar D420), Fiber Optic Receiver (1 ea.) (Darkstar D430), Cable Scanner (1 ea.) (Black Box, Corp. TS375A), Moisture Analyzer (1 ea.) (Meeco NEP-18), Dew Pointer (1 ea.) (Alnor 7200U), Megohmmeter (1 ea.) (Biddle Instruments 21805-2), Tachometer (2 ea.) (Power Instrument 1707), Tachometer (1 ea.) (Stewart-Warner 82682), Tachometer (3 ea.) (Electromatic Equipment DT-105), Tachometer (2 ea.) (SPM Instrument TAC-10), Snap-Around Transformer (2 ea.) (Amprobe CT-50-2), Powerline Analyzer (2 ea.) (Dranetz 606-3), Cool/Heat Calibrator (1 ea.) (JF Instruments EVJ-D-50-RC), Megger (1 ea.) (Associated Research 00293A), Crimper Kit (5 ea.) (Robinson Nugent HT-20), Fiber Splicing Kit (1 ea.) (GTE W01437), Electyrical Test Kit (1 ea.) (Mitchell Instruments MIT003), Clamp-On Multimeter (1 ea.) (TIF 1000), Tracer (1 ea.) (Tif Instruments 300HV), Sequence Detector (1 ea.) (Time Mark 108B), Indicator (1 ea. ) Time Mark 108C), Analog Oscilloscope (1 ea.) (B&K Precision 2190B), Drill Motor (1 ea.) (Ingersoll-Rand 00B2), Air Saw (1 ea.) (Air Speed J). USED Lot # 04 Blade Kit (2 ea) (Jacobson 502842), Reel Blade (12 ea.) (Jacobsen 502671), Blade (40 ea.)(Jacobson 337599), also includes other Jacobson items including additional blades, throttle cables, and more. Gear Box Assembly (1 ea.) (Bush Hog 865), Drive Shaft (1 ea.) (Bush Hog MDL3615), also includes other Bush Hog items. USED/UNUSED

Lot # 05 Optical Level (1 ea.) (Wild N3), Optical Level (1 ea.) (Keuffell & Esser 9092-3), Transit Square (1 ea.) Brunson M76-RH), Transit (1 ea.) (Keuffel & Esser No. 74-0000), Tripod (2 ea.) (Keuffell & Esser #78-0030), Tripod (1 ea.) (Wild GST20), Tripod (1 ea.) (Lietz 7536-75), Leveling Rod (1 ea.) (Philadelphia C), Temperature Tester (1 ea.) (Robinair 14840), Thermometer (3 ea.) (CPS TM250), Leak Seeker (1 ea.) (Tramex CO1500-18001), Leak Detector (1 ea.) (Johnson Controls RLD-H10G), Leak Detector (1 ea.) (Davis Instruments TIF 5000), Electronic Sight Glass (1 ea.) (TIF Instruments TIF4000), Leak Detector (2 ea.) (Penn RLD-H10G), Vane Anemometer (2 ea.) (Davis A/2-4IN-BB), Halogen Leak Detector (4 ea.) (TIF Instruments 5680), Velocity Indicator (1 ea.) (Davis A), Leak Detector (1 ea. ) (Johnson Controls RLD-H10G, Thermohygrometer (1 ea.) (Hanna Instruments U1149231), Thermohygrometer (1 ea.) (Hanna Instruments H193640), Programmable Meter (2 ea.) (Johnstone 9050), Air Velocity Meter (1 ea.) (Dwyer 400), Light Meter (1 ea.) (General Electric 214), Oxygen Analyzer (1 ea.) (Alpha Omega 2520-F2RMX), Leak Detector (1 ea.) (EFI, Inc. EI-701), Thermohygrometer (2 ea.) (Hanna Instruments HI93640), Digital Thermometer (1 ea.) (Analogic Corp. AN6520-8A-110), Splice Tool Kit (1 ea.) (Siecor TKT-100-01), Handheld Calibrator (1 ea.) (Rosemount 268), Portable Microscope (1 ea.) (Buehler 0801-9505), Fiber Optic Cable Kit (1 ea.) (Wang Labs 725-1353), Coax Crimper (3 ea.) Paladin PA1615), Single Level Meter (2 ea.) (Trilithic 600), Infared Scanner (1 ea.) (AGA Thermovision 110), Cable Tester (8 ea.) (Independent Technology ITC -3002), Cable Scanner (1 ea.) (Black Box Corp. TS375A), Fiber Optic Test Set (1 ea.) (Siecor Corp. TFB-03-03010), Moisture Detector (1 ea.) (Tramex, Inc.). USED Lot # 06 Pipe Threader in metal box (4 eal.) (Rigid A), Jackhammer (1 ea.) (Chicago Pneumatic CP-124), Jackhammer (2 ea.) (Thor #75), Jackhammer (1 ea.) (Chicago Pneumatic R93985-69), Jacknammer (1 ea.) (Gardner-Denver (1 ea.) (B87C), Jackhammer (1 ea.) (Thor 375), Jackhammer (1 ea.) (Bosch 0611304034), Drill Motor (1 ea.) (Mueller Co. H603), Puller Set (1 ea.) (Snap-On CG-120-13) and more. USED Lot # 07 Overhead Projector (1 ea.) (American Optical Apoll06), Transparancy Maker (1 ea.) (3-M 4550AGA), Portable Computer (1 ea.) (Sharp PC-7100), Chromameter W/Data Processing Head (1 ea.) (Minolta Camera CR310), Light Show Presenter (1 ea.) (In-Focus Systems Lite Show 2), Overhead Projecter (2 ea.) (In-Focus Systems 360P), Camcorder (1 ea.) (Panasonic PVD486), Field Indicator (1 ea.) (Magnaflus Corp. 0-10+-), Line Signal Conditioner (1 ea.) (Marco Sensors LCP-2000-100 115V.), Printer Server (2 ea.) (Troy 2915), Overhead Projector (1 ea.) (Apollo Legend). USED Lot # 08 Compressor (1 ea.) (Trane CSHC100K0A0C P/N 570008503400), Fan Motor (1 ea.) (Trane F48M02AH.P. 380-415/460 Volts), Capacitor (1 ea.) (Trane X13040385040) In original cartons. USED/UNUSED

Lot # 09 Overhead Projector (1 ea.) (Visual Systems 910), Overhead Projector (1 ea.) (3-M Corp 900AJC), Overhead Projector (1 ea.) (Bell & Howell 389B), Overhead Projector (1 ea.) (Buhl 2963), Desktop Computer (5 ea.), Laminator (1 ea.) (Datacode Pouch 41N), Specialty Printer (1 ea.) (Fargo 081822), Identification Card Printer (1 ea.) (Fargo 081822), Camera Light (1 ea.) (Lowel Company Pro Light), Camera (1 ea.) (PGI Corp. CSC 740), Camera TriPod (2 ea.) (Vanguard OV-500). USED Lot # 10 Tool Set (Metric) (1 ea.) (Snap-On), Air Fastner Shot Gun (2 ea.) (Darwin ZS), Electric Staple Gun (3 ea.) (EWB-5018), Hydraulic Punch Driver (1 ea.) (Greenlee 7804SB), Sander/Grinder (1 ea.) (Black & Decker TYP4), Right Angle Grinder (1 ea.) (Black & Decker CAT 4052), Weld Gun (3 ea.) (Chicago Pneumatic 455), Belt Sander (1 ea.) (Skil 449), 3 Planer (2 ea.) (Black & Decker 3370-10), Impact Hammer (1 ea.) (Phillips 457), Rotary Hammer (1 ea.) (Black & Decker 5043-09), Paint Spray System (2 ea.) (Wagner 0154332), Air Drill Motor (1 ea.) (Chicago Pneumatic CP-9288), Relative Generator (1 ea.) (General Eastern C-1RH) USED Lot # 11 Bar-Code Scanner (2 ea.) (Welch Allyn 3800LR-12), Media Converter (1 ea.) (Transition E-100BTX-FX-05-MT), Desk-Top Computers (37 ea.) (Dell and Tristar). USED Lot # 12 Water Sampler Mixer (1 ea.) (Phipps & Bird 300), Turbidimeter (1 ea.) (Hach 2100A), PH Meter (1 ea.) (Hach 19000), Zero Head Extractor (1 ea.) (Milipore Spec RFC 783), Spectrophotometer (1 ea.) (Hach Chemical DR400/PN 48100-600), Conductivity Meter (1 ea.) (Hach C0150), Test Unit (1 ea.) (MultiAmp SR5), Oil Port Tester (1 ea.) (GE 9T11Y8454), Transformer Tester (1 ea.) (AVO 0TS60SX), USED Lot # 13 Thermal Printer (1 ea.) (Eastman Kodak 8670PS), Desktop Computers (5 ea.) (Dell 4100), Computers (5 ea.) (Dell Dimension 4600) and more. USED Lot # 14 Hand Operated Jack Systems includes a few attachments (7 ea.) (Various Manufacturers) USED Lot # 15 File Server (4ea.) (Compaq Series 4030), File Server (Compaq 273370-001), File Server DPI Net100E/N), Notebook Computer (1 ea.) (Dell Inspiron 8000), Handheld PC w/smart pad (1 ea.) (Compaq 3635), Ray Terminal (1 ea.) (Sun 102), Laptop Computer (1 ea.) (Dell X300), Laser Printer (1 ea.) (Hewlett-Packard 38491A), and more. USED
Lot # 16 Enclosed Trailer (2 ea.) 8W x 10L x 7.5H - (dual-axel 15 wheels) (Rochelle Steel RSBR-100E), Utility Trailer (2 ea.) 5 W x 8L (single-axel 15 wheels) (Parker 2K USED
Lot # 17 Surface Plate (1 ea.) (Doall B), Power Hack Saw (1 ea.) (Armstrong-Blum 9/SI/S2), Electric Weld Rod Oven (1 ea.) (Despatch RSO), Drill Press (1 ea.) (Houdaille 1150A), Arbor Press (1 ea.) (Greenerd Arbor #4), Hydraulic Press (1 ea.) (Dake 25H), Arbor Press (1 ea.) (Greenerd Arbor 3E), Bench Grinder w/table (1 ea.) (Black & Decker #76) USED Lot # 18 Scissor Lift (1 ea.) (Figgle Hunter #2135 S/N 290C42SP USED

Lot # 19 Large lot of misc. small Shop Items including nuts, switches, flanges, O-rings, boards, seals, pins, nozzles, caps, bearings, gaskets, springs, vacuum bags, and more. USED/UNUSED Lot # 20 DVD Player (1 ea.) (Sony DRX-530UL), LapTop Computer (2 ea.) (Toshiba PR127OU XCD), LapTop Computer (1 ea.) (Toshiba PR127OU-T2C), Computer (10 ea.) (Dell Dimension 4600), Computer (24ea.) (Dell Dimension 4500), Computer (8 ea.) (Dell Dimension 8300), Monitor (1 ea.) (17 Dell E172FP USED Lot # 21 Computer (11ea.) (Dell GX270), Computer (1 ea.) (Dell Dimension 4600), Computer (1 ea.) (Dell Dimension 8300), Monitor (1 ea.) (Viewsonic VCDTS) USED