A S K T H E E X P E R T Children exposed to bats: Evidence-based management strategies John S. Murray, Marcia K. Stephens, and Parag M. Amin Column Editor: Martin Schiavenato Ask the Expert provides research-based answers to practice questions submitted by JSPN readers. Search terms Bat exposure, children, rabies Author contact [email protected], with a copy to the Editor: [email protected] Disclosure: The authors report no actual or potential conflicts of interest. doi: 10.1111/jspn.12082 Question: What are the current recommenda- tions for pediatric healthcare professionals managing bat exposure in children? John S. Murray, PhD, RN, CPNP, FAAN, Marcia K. Stephens, RN, and Parag M. Amin, MD respond: In the United States, there are approxi- mately 40 different species of bats. While most bats are harmless, and various types are even beneficial (e.g., those that feed on insects harmful to crops), some may be infected with, and transmit, rabies. Public health concern regarding rabies has changed dramatically over the past several decades. Before the 1960s, most cases of rabies involved domestic animals (e.g., dogs and cats). Today the primary hosts for rabies are wild predatory animals (e.g., raccoon, fox, and coyote) and bats. In fact, in the United States, the most common source of rabies transmission to humans is from bats (Figure 1; Baker, 2012; Centers for Disease Control and Prevention [CDC], 2011a; CDC Advisory Committee on Immunization Practices [ACIP], 2008; National Association of State Public Health Veterinarians, 2011). While death from rabies is a rare occurrence in the United States, it is estimated that 16,000–39,000 people annually are exposed to poten- tially rabid animals requiring post-exposure care (CDC Immunization Action Coalition, 2013). TYPES OF EXPOSURE Under most circumstances, two types of exposure to bats are possible: bite and non-bite (CDC, 2011b; CDC ACIP, 2008; DeMaria, 2014). Bites are defined as any penetration of the skin by the teeth of a bat. This route of exposure is considered to be the most serious. However, bat bites are often so small, and with limited injury, that they go unnoticed (Figure 2). Rabies exposure can also occur when the virus, from poten- tially infectious secretions of the bat such as saliva, come in contact with open cuts, scratches, abrasions, or the mucous membranes of a child. Other situations that qualify as exposure include a bat found in prox- imity to a child who is not able to describe what hap- pened or who is unable to rule out the occurrence of direct contact, or a parent who witnesses a live bat in a room where a child was unattended at the time (e.g., bedroom, playroom). Additionally, a bat located on the floor where an infant, toddler, or child with sensory or mental impairment is situated is also con- sidered to be a contact risk. If there is ever a question regarding exposure, state and local health depart- ments should be contacted for guidance. The type of c.

1. A S K T H E E X P E R T
Children exposed to bats: Evidence-based
management strategies
John S. Murray, Marcia K. Stephens, and Parag M. Amin
Column Editor: Martin Schiavenato
Ask the Expert provides research-based answers to practice
questions submitted by JSPN readers.
Search terms
Bat exposure, children, rabies
Author contact
[email protected], with a copy to the Editor:
[email protected]
Disclosure: The authors report no actual or
potential conflicts of interest.
doi: 10.1111/jspn.12082
Question: What are the current recommenda-
tions for pediatric healthcare professionals
managing bat exposure in children?
John S. Murray, PhD, RN, CPNP, FAAN, Marcia
K. Stephens, RN, and Parag M. Amin, MD
respond: In the United States, there are approxi-
mately 40 different species of bats. While most bats are
harmless, and various types are even beneficial (e.g.,

2. those that feed on insects harmful to crops), some may
be infected with, and transmit, rabies. Public health
concern regarding rabies has changed dramatically
over the past several decades. Before the 1960s, most
cases of rabies involved domestic animals (e.g., dogs
and cats). Today the primary hosts for rabies are wild
predatory animals (e.g., raccoon, fox, and coyote) and
bats. In fact, in the United States, the most common
source of rabies transmission to humans is from bats
(Figure 1; Baker, 2012; Centers for Disease Control
and Prevention [CDC], 2011a; CDC Advisory
Committee on Immunization Practices [ACIP], 2008;
National Association of State Public Health
Veterinarians, 2011). While death from rabies is a rare
occurrence in the United States, it is estimated that
16,000–39,000 people annually are exposed to poten-
tially rabid animals requiring post-exposure care (CDC
Immunization Action Coalition, 2013).
TYPES OF EXPOSURE
Under most circumstances, two types of exposure to
bats are possible: bite and non-bite (CDC, 2011b; CDC
ACIP, 2008; DeMaria, 2014). Bites are defined as any
penetration of the skin by the teeth of a bat. This route
of exposure is considered to be the most serious.
However, bat bites are often so small, and with limited
injury, that they go unnoticed (Figure 2). Rabies
exposure can also occur when the virus, from poten-
tially infectious secretions of the bat such as saliva,
come in contact with open cuts, scratches, abrasions,
or the mucous membranes of a child. Other situations
that qualify as exposure include a bat found in prox-
imity to a child who is not able to describe what hap-
pened or who is unable to rule out the occurrence of

3. direct contact, or a parent who witnesses a live bat in a
room where a child was unattended at the time (e.g.,
bedroom, playroom). Additionally, a bat located on
the floor where an infant, toddler, or child with
sensory or mental impairment is situated is also con-
sidered to be a contact risk. If there is ever a question
regarding exposure, state and local health depart-
ments should be contacted for guidance. The type of
contact will determine what post-exposure care is
required (Baker, 2012; CDC ACIP, 2008; DeMaria,
2014; De Serres et al., 2009).
The most common source of rabies transmission in the
U.S. is the bat; therefore, any potential exposure
requires a thorough evaluation.
RABIES POST-EXPOSURE CARE
Critical to the care of a child exposed to a bat is
immediate wound treatment and the appropriate
administration of human rabies immune globulin
bs_bs_banner
Journal for Specialists in Pediatric Nursing
350 Journal for Specialists in Pediatric Nursing 15 (2014) 350–
353
© 2014, Wiley Periodicals, Inc.
mailto:[email protected]
mailto:[email protected]
and vaccine (CDC ACIP, 2008). Treatment of
wounds includes thoroughly washing and rinsing

4. any bites or scratches for 10–15 min using soap and
water. Care of the wound should occur immediately,
or as early as possible if access to soap and water is
not readily available (CDC ACIP, 2008; World Health
Organization [WHO], 2013). Administration of
rabies post-exposure prophylaxis (PEP) should be
considered urgent, but not a medical emergency.
Important to treatment is ensuring that the proper
exposure assessment takes place before PEP begins.
Discussion regarding appropriate rabies post-
exposure care should occur between pediatric
healthcare providers and local public health officials
(CDC ACIP, 2008). Excellent resources for guiding
conversations regarding treatment are the ACIP
rabies guidelines found at http://www.cdc.gov/
vaccines/hcp/acip-recs/vacc-specific/rabies.html as
well as the American Academy of Pediatrics (AAP,
2014) Red Book® Online (http://intl-aapredbook
.aappublications.org/).
Once it is determined that exposure occurred,
active immunization is accomplished by administer-
ing rabies vaccines. Rabies prophylaxis includes the
administration of two vaccines: rabies immune
globulin (RIG) and human diploid cell vaccine
(HDCV), or purified chick embryo cell vaccine
(PCECV). RIG provides temporary passive protection
while HDCV and PCECV offer longer-acting coverage
(Baker, 2012; CDC, 2011c). Typically RIG is adminis-
tered at a dose of 20 IU/kg in the emergency depart-
ment (ED) and is given only once on the day the child
presents for treatment. Administration of HDCV or
PCECV involves multiple doses at prescribed inter-
vals (days 0, 3, 7, and 14). Prior to 2009, ACIP recom-
mended a series of five doses of HDCV or PCECV.

5. Following a thorough review of evidence available
from basic and applied research of rabies prevention,
the number of vaccine doses was reduced to four
(CDC ACIP, 2010). The first dose (day 0) is adminis-
tered along with RIG on the day of presentation for
PEP. The recommended dose of HDCV or PCECV is
1 mL (2.5 IU of rabies antigen) regardless of the
child’s age or weight. The vaccine is administered
intramuscularly into the deltoid muscle (AAP
Committee on Infectious Diseases, 2011; Baker,
2012; CDC, 2009, 2011c; WHO, 2012). It is important
that the four doses of vaccine be given on schedule. If
there is any deviation from the timeline, the vaccine
manufacturer should be contacted for guidance on
completing the course of treatment. The vaccine
packaging contains the contact information to call for
assistance (Baker, 2012).
As with any vaccine administered to children,
pediatric healthcare professionals should be aware
of potential side effects. The most common reactions
to rabies vaccines are soreness, erythema, and
edema at the injection site. Other common com-
plaints include headache, nausea, myalgias, and diz-
ziness (CDC ACIP, 2008; WHO, 2012).
HOW PEDIATRIC HEALTHCARE PROVIDERS
CAN HELP
Key to addressing the concern of bat exposure and
rabies is raising awareness at the community level
regarding transmission and what to do when a child is
exposed to the virus. The CDC (2011d) recommends
Figure 1 Little Brown Bat (Myotis lucifugus) in Eave of a
House.

6. Source: Wildlife North America. This work is in the public
domain.
Figure 2 Wound Inflicted by Teeth of Eptesicus fuscus (Big
Brown Bat).
Source: Centers for Disease Control and Prevention. This work
is in the
public domain.
J. S. Murray et al. Ask the Expert
351Journal for Specialists in Pediatric Nursing 15 (2014) 350–
353
© 2014, Wiley Periodicals, Inc.
http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-
specific/rabies.html
http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-
specific/rabies.html
http://intl-aapredbook.aappublications.org/
http://intl-aapredbook.aappublications.org/
that healthcare professionals take an active role
in educating families about rabies exposure. For
clinicians with no or limited experience with evaluat-
ing and treating pediatric patients exposed to the
rabies virus, an Internet-based course designed
to educate healthcare professionals is readily
available (http://www.cdc.gov/rabies/resources/
training/index.html). The course covers a general
introduction to rabies followed by case studies that
encompass varying aspects of conducting a risk
assessment as well as PEP administration (CDC,
2011d).

7. Pediatric healthcare professionals can also play a
significant role by providing guidance to patients and
parents regarding avoiding exposure to bats. Bats can
be found living in attic spaces, rafters, chimneys,
porches, and walls of homes. Bats are particularly
inclined to roost in older homes and buildings as
shelter from the weather and protection from other
animals. It is possible for bats to enter spaces as small
as one-fourth inch (CDC, n.d.). Reducing exposure to
bats entails understanding and sharing with families
specific recommendations. For many areas in the
United States, bats leave homes and other structures
beginning in the fall to hibernate. This provides an
opportunity for families to bat-proof their homes to
prevent bats from returning. All openings should be
sealed appropriately to prevent re-entrance. For
example, windows should have screens, chimneys
covered with screens, and openings for plumbing and
electrical fittings sealed with caulk, wire mesh, or
wood fittings. When in doubt regarding the most
appropriate preventive measures, families should
contact a licensed pest control expert specializing in
bat control or the local or state health department
(CDC, 2011e). Bat Conservation International
(2013) offers an excellent guide for families on bat-
proofing homes and buildings: http://www.batcon
.org/pdfs/education/fof_ug.pdf
CONCLUSION
Bats are of significant importance to the world’s eco-
systems. Nevertheless, most rabies cases in the United
States are caused by viruses associated with bats;
thus, potential exposures to bats involving children
do occur, often requiring PEP. Pediatric healthcare

8. professionals should have an understanding of PEP,
bat exposure resources, and always consult with local
public health experts for assistance in determining
the risk associated with a particular exposure to a bat
and the requisite treatment. Continued efforts
focused on preventing exposure of children to
sources of virus, and the recognition and adherence
to appropriate and timely prophylaxis after exposure
remain the most effective public health measures to
prevent human rabies (CDC ACIP, 2008).
CASE STUDY
The mother of TM (8 years old) and KM (6 years old)
reported to their pediatric primary care provider that
4 days ago, when the children were asleep in the
same room, they awoke to find a bat flying around
the room and hitting the window shades. Both
parents witnessed the same. The mother was
instructed to take her children to the local ED for
evaluation and treatment. Upon exam, neither child
had visible bites or scratches. Given the bat was
found in the same room as the children while sleep-
ing, the decision was made by the ED provider and
local public health officer to proceed with human
rabies immune globulin (20 IU/kg) and rabies
vaccination (RabAvert®) 1 mL intramuscularly.
Subsequently, repeat doses of RabAvert® were
administered on days 3, 7, and 14 at the primary
care practice. The only difficulty experienced by the
children was soreness at the injection site.
John S. Murray, PhD, RN, CPNP, FAAN
Pediatric Nurse

9. Centre Pediatric Associates, P.C.
Brookline, Massachusetts, USA
Marcia K. Stephens, RN
Newton, Massachusetts, USA
Parag M. Amin, MD
Pediatrician
Centre Pediatric Associates, P.C.
Brookline, Massachusetts, USA
SELECT RESOURCES
Organization Website
Centers for Disease Control
and Prevention Advisory
Committee on
Immunization Practices
http://www.cdc.gov/vaccines/acip/
Centers for Disease Control
and Prevention
http://www.cdc.gov/rabies/bats/
education/index.html
World Health Organization http://www.who.int/rabies/human/

10. postexp/en/
Ask the Expert J. S. Murray et al.
352 Journal for Specialists in Pediatric Nursing 15 (2014) 350–
353
© 2014, Wiley Periodicals, Inc.
http://www.cdc.gov/rabies/resources/training/index.html
http://www.cdc.gov/rabies/resources/training/index.html
http://www.batcon.org/pdfs/education/fof_ug.pdf
http://www.batcon.org/pdfs/education/fof_ug.pdf
http://www.cdc.gov/vaccines/acip/
http://www.cdc.gov/rabies/bats/education/index.html
http://www.cdc.gov/rabies/bats/education/index.html
http://www.who.int/rabies/human/postexp/en/
http://www.who.int/rabies/human/postexp/en/
References
American Academy of Pediatrics. (2014). Red Book®
online. Retrieved from http://intl-aapredbook
.aappublications.org/
American Academy of Pediatrics Committee on Infectious
Diseases. (2011). Policy statement—Rabies-prevention
policy update: New reduced-dose schedule. Pediatrics,
127(4), 785–787. doi:10.1542/peds.2011-0095
Baker, M. D. (2012). Editorial: Update on rabies exposure and
vaccine prophylaxis. Retrieved from http://www.healio
.com/pediatrics/vaccine-preventable-diseases/news/
print/infectious-diseases-in-children/%7Be408b4e6
-7bc3-493a-a637-9fb8de6fd53a%7D/update-on-rabies
-exposure-and-vaccine-prophylaxis

11. Bat Conservation International. (2013). Bats in buildings: A
guide to safe & humane exclusions. Retrieved from
http://www.batcon.org/pdfs/education/fof_ug.pdf
Centers for Disease Control and Prevention. (2009). Rabies
vaccine: What you need to know. Retrieved from
http://www.immunize.org/vis/rabies.pdf
Centers for Disease Control and Prevention. (2011a).
Rabies in the U.S. Public health importance of rabies.
Retrieved from
http://www.cdc.gov/rabies/location/usa/index.html
Centers for Disease Control and Prevention. (2011b).
Rabies: What type of exposure occurred? Retrieved from
http://www.cdc.gov/rabies/exposure/type.html
Centers for Disease Control and Prevention. (2011c).
Human rabies immune globulin. Retrieved from
http://www.cdc.gov/rabies/medical_care/hrig.html
Centers for Disease Control and Prevention. (2011d).
Rabies training. Retrieved from http://www.cdc.gov/
rabies/resources/training/index.html
Centers for Disease Control and Prevention. (2011e).
Keeping bats out of your house. Retrieved from http://
www.cdc.gov/rabies/bats/management/index.html
Centers for Disease Control and Prevention. (n.d.). Bats:
Safety and risk management at camp. Retrieved from
http://www.cdc.gov/rabies/pdf/bats_final_508.pdf
Centers for Disease Control and Prevention Advisory
Committee on Immunization Practices. (2008). Human

12. rabies prevention—United States, 2008. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/
rr5703a1.htm
Centers for Disease Control and Prevention Advisory
Committee on Immunization Practices. (2010). Use of a
reduced (4-dose) vaccine schedule for postexposure prophylaxis
to prevent human rabies. Retrieved from
http://www.cdc.gov/mmwr/pdf/rr/rr5902.pdf
Centers for Disease Control and Prevention Immunization
Action Coalition. (2013). Rabies: Questions and answers.
Information about the disease and vaccines. Retrieved from
http://www.immunize.org/catg.d/p4216.pdf
DeMaria, A. (2014). When to use rabies prophylaxis.
Retrieved from http://www.uptodate.com/
contents/when-to-use-rabies-prophylaxis
De Serres, G., Skowronski, D. M., Mimault, P., Ouakki, M.,
Maranda-Aubut, R., & Duval, B. (2009). Bats in the
bedroom, bats in the belfry: Reanalysis of the rationale
for rabies postexposure prophylaxis. Clinical Infectious
Diseases, 48, 1493–1499. doi:10.1086/598998
National Association of State Public Health Veterinarians.
(2011). Compendium of animal rabies prevention and
control, 2011. Morbidity and Mortality Weekly Report.
Recommendations and Reports/Centers for Disease Control,
60(6), 1–14.
World Health Organization. (2012). Information sheet:
Observed rates of vaccine reaction—rabies vaccine. Retrieved
from http://www.who.int/vaccine_safety/initiative/
tools/Rabies_Vaccine_rates_information_sheet.pdf

13. World Health Organization. (2013). Rabies. Retrieved
from http://www.who.int/mediacentre/factsheets/
fs099/en/
J. S. Murray et al. Ask the Expert
353Journal for Specialists in Pediatric Nursing 15 (2014) 350–
353
© 2014, Wiley Periodicals, Inc.
http://intl-aapredbook.aappublications.org/
http://intl-aapredbook.aappublications.org/
http://www.healio.com/pediatrics/vaccine-preventable-
diseases/news/print/infectious-diseases-in-
children/%257Be408b4e6-7bc3-493a-a637-
9fb8de6fd53a%257D/update-on-rabies-exposure-and-vaccine-
prophylaxis
http://www.healio.com/pediatrics/vaccine-preventable-
diseases/news/print/infectious-diseases-in-
children/%257Be408b4e6-7bc3-493a-a637-
9fb8de6fd53a%257D/update-on-rabies-exposure-and-vaccine-
prophylaxis
http://www.healio.com/pediatrics/vaccine-preventable-
diseases/news/print/infectious-diseases-in-
children/%257Be408b4e6-7bc3-493a-a637-
9fb8de6fd53a%257D/update-on-rabies-exposure-and-vaccine-
prophylaxis
http://www.healio.com/pediatrics/vaccine-preventable-
diseases/news/print/infectious-diseases-in-
children/%257Be408b4e6-7bc3-493a-a637-
9fb8de6fd53a%257D/update-on-rabies-exposure-and-vaccine-
prophylaxis
http://www.healio.com/pediatrics/vaccine-preventable-
diseases/news/print/infectious-diseases-in-
children/%257Be408b4e6-7bc3-493a-a637-
9fb8de6fd53a%257D/update-on-rabies-exposure-and-vaccine-

14. prophylaxis
http://www.batcon.org/pdfs/education/fof_ug.pdf
http://www.immunize.org/vis/rabies.pdf
http://www.cdc.gov/rabies/location/usa/index.html
http://www.cdc.gov/rabies/exposure/type.html
http://www.cdc.gov/rabies/medical_care/hrig.html
http://www.cdc.gov/rabies/resources/training/index.html
http://www.cdc.gov/rabies/resources/training/index.html
http://www.cdc.gov/rabies/bats/management/index.html
http://www.cdc.gov/rabies/bats/management/index.html
http://www.cdc.gov/rabies/pdf/bats_final_508.pdf
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5703a1.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5703a1.htm
http://www.cdc.gov/mmwr/pdf/rr/rr5902.pdf
http://www.immunize.org/catg.d/p4216.pdf
http://www.uptodate.com/contents/when-to-use-rabies-
prophylaxis
http://www.uptodate.com/contents/when-to-use-rabies-
prophylaxis
http://www.who.int/vaccine_safety/initiative/tools/Rabies_Vacc
ine_rates_information_sheet.pdf
http://www.who.int/vaccine_safety/initiative/tools/Rabies_Vacc
ine_rates_information_sheet.pdf
http://www.who.int/mediacentre/factsheets/fs099/en/
http://www.who.int/mediacentre/factsheets/fs099/en/
Applied Vegetation Science 17 (2014) 604–608
FORUM
Evidence-based vegetation management: prospects
and challenges
Per Milberg

15. Keywords
Applied research; Evidence based; Knowledge
transfer; Manager; Metaanalysis
Received 29 October 2013
Accepted 28 January 2014
Co-ordinating Editor: Michael Palmer
Milberg, P. ([email protected]): IFM Biology,
Conservation Ecology Group, Link€oping
University, Link€oping, SE-581 83, Sweden
Abstract
The effect of applied vegetation science on society has the
potential to increase
by adopting an evidence-based approach. However, this would
require a shift in
focus towards effect size and results suitable for meta-analyses,
a focus on practi-
tioners as potential readers, more emphasis on practical
problems rather than
mechanism, and an acceptance of all well-executed
experimental studies, even
if confirmatory. Thus, the prevailing editorial policies need to

16. be reconsidered,
as well as the methods of analysing, reporting and evaluating
research, for our
research efforts to be of better use within society.
Background
Some of us work in applied research, but what does
‘applied’ actually mean? I prefer to think of ‘applied
research’ as being of more direct interest to society and that
there are – beyond fellow researchers – two potential
groups targeted by such research (Cook et al. 2013)
1
. The
first group is policy-makers, a group that consists of people
who prepare and make new laws, as well as government
or company officials who set up rules for activities in
society or within their organization. The second group is
managers, which consists of people who make operational
decisions and their advisors (e.g. medical doctors, teach-
ers, foresters, farmers, extension officers). It is our hope
that the managers within our field regularly read Applied

17. Vegetation Science and similar journals. However, the pro-
cess of knowledge transfer from applied research to prac-
tice is often disappointing (e.g. Nutley et al. 2007; Braun &
Hadwiger 2011; Dagenais et al. 2012; Rojek et al. 2012).
Poor or slow knowledge transfer indicates missed opportu-
nities and a waste of resources, both in science and society.
But there are ways in which we researcher, the ‘donors’ of
knowledge, can facilitate this process.
In our field, managers who are potentially interested in
our work are often highly educated. However, do we have
them in mind when we write our papers? Or is it that our
focus has gradually shifted from the potential end-user of
our findings to a concentration on the continuously tight-
ening requirements by the scientific community to pass
the editorial and review processes?
A reform in the way we think about, analyse and
present our applied research is welcome, and it would
affect authors, referees and editorial policies. With such

18. a reform, our research might have a greater impact in
society, and this is what applied research should strive to
achieve.
An example of the failure to communicate
I recently experienced how my own research and that
of others was ignored (or not known) by policy-makers
and practitioners: a notion that I believe not to be uncom-
mon among applied researchers (Cook et al. 2013). More-
over, I realized that the fault was not entirely theirs:
nice ordination analyses do not communicate well with
busy managers. Furthermore, the results that I had pub-
lished did not provide any estimate of effect size, which
is often the main focus of a manager. Or put another
way, a significant P-value is of much less interest than
a number showing how much two treatments differ (Di
Stefano et al. 2005; Cumming 2012). It is only with an
effect size that a manager can properly weigh the costs
against benefits. I should have considered practitioners

19. when publishing, but seem to have forgotten that anyone
outside academia might be interested. As a minimum, I
could have formulated clear and explicit recommendations
for practitioners (Memmott et al. 2010; Simonetti 2011).
So, I have no reason to blame the policy-makers and
practitioners that failed to find my study in the vast ocean
of published research.
1
Research also has an educational role towards the general
public, but this
role is a joint role of both applied and basic research.
Applied Vegetation Science
604 Doi:10.1111/avsc.12114 © 2014 International Association
for Vegetation Science
Learning from reforms in other fields of applied
research
Other fields of applied research have embraced evidence-
based management (Hansen & Rieper 2009). In short,
management (or policy) should be based on the best

20. available knowledge. This might appear as a rather trivial
statement, but new findings often take considerable time
before translating into action, thereby wasting the
resources society has invested in research. For example,
Gilbert et al. (2005) estimated that if a recommendation
(sleeping position of infants) had been changed when the
evidence was available, rather than after 25 yrs, 10,000
lives could have been saved in the UK alone. In another
example, a systematic review showed that costly methods
used (to increase salmonid fish abundance by in-stream
structures) for 80 yrs were of rather doubtful value
(Stewart et al. 2009). Within medicine, all parties includ-
ing taxpayers, insurance companies and patient’s next-of-
kin, expect doctors to make a well-informed decision. The
medical field is also where the evidence-based movement
has experienced its greatest achievements: evidence-based
medicine was voted among one of the ten most important
medical advances during the last centuries (Ferriman

21. 2007). Aided by meta-analyses, systematic reviews are the
foundation of evidence-based medicine. In such a review,
which focuses on a specific question rather than a conven-
tional review, a literature search is performed systemati-
cally, and studies are selected for inclusion according to
predefined criteria and, most often, the published numbers
are entered into meta-analyses. Thus, all relevant informa-
tion can be quantitatively summarized, and doctors can
base their treatment alternatives on such reviews.
Not all fields have such simple outcome variables as
medicine, and might involve more complex decisions by
managers. Furthermore, meta-analysis and systematic
reviews has created new challenges (Kueffer et al. 2011;
Lindenmayer & Likens 2013). However, this does not
preclude benefits to society by adopting an evidence-based
approach within an area (e.g. Hattie 2009). Furthermore,
within the last several years, evidence-based move-
ments within environmental management have emerged

22. (www.environmentalevidence.org, www.eviem.se, www.
cebc.bangor.ac.uk). In fact, there are already a number of
published systematic reviews focused on vegetation man-
agement (e.g. Newton et al. 2009; Kettenring & Adams
2011; Humbert et al. 2012).
The new statistics
Importantly, a ‘statistical reform’ is currently underway,
where a shift away from P-values to a focus on effect sizes
can be observed (Fidler et al. 2004; McCloskey & Ziliak
2009; Cumming 2012). This is a cornerstone in evidence-
based management and goes hand-in-hand with meta-
analyses. As an indication of how far this reform has come
in some fields, Epidemiology, a major journal in its field,
already in 1998 stated in the instructions for authors that,
“When writing for Epidemiology, you can also enhance your
prospects if you omit tests of statistical significance. . . In
Epidemiology, we do not publish them at all” (Rothman
1998). In contrast, ecologists seem to continue to think that

23. null hypotheses and P-values are essential for publication.
Neither meta-analyses nor ‘statistical reform’ is new to
ecology (e.g. Fidler et al. 2004; Koricheva et al. 2013;
Vetter et al. 2013). The use of meta-analyses among ecolo-
gists, however, has not been within the context of evi-
dence-based management, but rather to support reviews
primarily aimed for other researchers. So time should be
ripe for its usage also in management-related questions,
with a focus on (i) ‘what works best’ (rather than on pro-
cesses and mechanisms) and on (ii) practitioners as poten-
tial readers (rather than on researchers only). Another
new consideration, which has bearing on all research pub-
lished, is to ensure that your data presentation allows
inclusion in future meta-analyses (i.e. a focus on effect
sizes rather than P-values). Imagine the horror when you
realize that all of your research effort is nullified by being
excluded from the next systematic review. Thus, the
presence of systematic reviews has resulted in greater con-

24. formity in how the medical researcher decides to design
and particularly analyse and present data from clinical
trials (and more recently, also in placing data in data
repositories). In contrast, ecologists seem to strive for
diversity in analysis and presentation.
New tools needed to enable meta-analysis of
vegetation data
Vegetation is complex, often species-rich, and thus com-
plex to analyse, and our field has a long history of relying
on various multivariate methods of analysis (e.g. Kent &
Ballard 1988; Masing 1994). However, because the
vegetation composition varies over sites and situations, it
is not always easy to analytically compare results of
experiments from different studies with multivariate
methods. Of course, there are other methods to simplify
data that might be more appropriate for meta-analysis
(e.g. Diekmann 2003; Milberg et al. 2014), and which can
be used to supplement more conventional multivariate

25. analyses. A substantial challenge for evidence-based
vegetation management is the development of a ‘common
currency’ suitable for meta-analysis. It might involve
increased effort in classification of species into desired/
undesired for particular management goals (Milberg et al.
2014).
605
Applied Vegetation Science
Doi:10.1111/avsc.12114 © 2014 International Association for
Vegetation Science
P. Milberg Evidence-based vegetation management
A reform has formidable enemies
It is somewhat paradoxical that despite the existence of
more journals and excellent literature search facilities, the
standards for publication have considerably tightened
and rejection rates have increased (Hochberg et al. 2009;
Jackson 2009). A few years ago, 75% of papers were
rejected by Applied Vegetation Science (Chiarucci et al.
2010), and this would be a typical value of an ecological

26. journal (Pautasso & Sch€afer 2010). The increasing rejec-
tion rates, noted by many (e.g. Jackson 2009; Statzner &
Resh 2010) indicate that much more effort has to go into a
study than once required (Campos-Arceiz et al. 2013).
There is also a risk that sound trials that have been con-
ducted remain unpublished (Scherer et al. 2007).
When editors have many manuscripts to choose from,
the key for a successful manuscript in most journals is no
longer whether a study is well conducted and with justified
conclusions, but the somewhat subjective and elusive
‘novelty factor’. Thus, if a study is merely confirmatory, as
judged by referees, or with non-significant results, then it
is less likely to be published (Dwan et al. 2008; Hopewell
et al. 2009). In the history of scientific publishing, this can
be seen as a shift in focus from documenting research
(‘anything that is well described and with conclusions
that are justified is OK’), to publishers and editors trying
to maximize profit and bibliometric outcomes, respec-

27. tively (e.g. Wellcome Trust 2003; Falagas & Alexiou 2008;
Statzner & Resh 2010). Considering the enormous volume
of published literature per year, we as readers might wel-
come this filtering of findings. However, knowledge is not
well built if only based on novelty and the extraordinary
or when there is a strong bias towards ‘significant’ results
(e.g. Ioannidis 2005; Knight 2006; Moonesinghe et al.
2007; Ridley et al. 2007; Fang & Casadevall 2011; Fanelli
2012; Giner-Sorolla 2012; Brodeur et al. 2013; Schoenfeld
& Ioannidis 2013).
Evidence-based management works best when all
well-executed studies are published and without delay.
In reality, there is a bias favouring exceptional results
while punishing the ‘uninteresting’. Thus, a reform would
need a resurrection of the value of confirmatory studies
(Asendorpf et al. 2013). In addition, we need to find a way
to document non-significant results (e.g. Kotze et al.
2004) that are of interest, at least if a study appears to have

28. been properly replicated.
Reform for both applied vegetation science and
Applied Vegetation Science?
Taken together, to enable the emergence of evidence-
based vegetation management, researchers need the fol-
lowing: (i) a shift in focus towards effect size and results
that are suitable for meta-analysis; (ii) to consider practi-
tioners as potential readers; (iii) more focus on practical
problems rather than mechanism; and (iv) acceptance of
well-executed confirmatory studies.
These above points have implications for editorial poli-
cies of all journals claiming to be a source for applied
research. So if Applied Vegetation Science wants to fully live
up to its name, why not an editorial demand for papers
with practical relevance, to present results in a manner
that enables future meta-analysis and to allow space for
confirmatory studies? Both Journal of Applied Ecology and
Ecological Applications claim practitioners as a target audi-

29. ence, why should Applied Vegetation Science be different?
And it would be excellent if Applied Vegetation Science aimed
to be an avenue for publication of systematic reviews, as
do the journals Biological Conservation and Environmental
Evidence.
Acknowledgements
I would like to thank referees and Lars Westerberg for
comments on an earlier version of the manuscript, and
extend the thanks also to other colleagues with whom I
have discussed ‘knowledge transfer’, statistical reform and
publication policy.
References
Asendorpf, J.B., Conner, M., De Fruyt, F., De Houwer, J.,
Denis-
sen, J.J.A., Fiedler, K., Fiedler, S., Funder, D.C., Kliegl, R.,
(. . .) &Wicherts, J.M. 2013. Recommendations for increasing
replicability in psychology. European Journal of Personality 27:
108–119.

30. Braun, S. & Hadwiger, K. 2011. Knowledge transfer from
research to industry (SMEs): an example from the food
sector. Trends in Food Science & Technology 22: S90–S96.
Brodeur, A., L�e, M., Sangnier, M. & Zylberberg, Y. 2013.
Star
Wars: The empirics strike back. Forschungsinstitut zur Zukunft
der Arbeit, Discussion Paper Series, No 7268.
Campos-Arceiz, A., Koh, L.P. & Primack, R.B. 2013. Are
conser-
vation biologists working too hard? Biological Conservation
166: 186–190.
Chiarucci, A., P€artel, M., D�ıaz, S. & Wilson, J.B. 2010.
Applied
Vegetation Science in 2010: new opportunities for the
vegetation scientists. Applied Vegetation Science 13: 1–4.
Cook, C.N., Possingham, H.P. & Fuller, R.A. 2013.
Contribution
of systematic reviews to management decisions. Conservation
Biology 27: 902–915.
Cumming, G. 2012. Understanding the New Statistics: effect
sizes, con-

31. fidence intervals, and meta-Analysis. Routledge, New York,
NY,
USA.
Dagenais, C., Lysenko, L., Abrami, P.C., Bernard, R.M.,
Ramde,
J. & Janosz, M. 2012. Use of research-based information by
school practitioners and determinants of use: a review of
Applied Vegetation Science
606 Doi:10.1111/avsc.12114 © 2014 International Association
for Vegetation Science
Evidence-based vegetation management P. Milberg
empirical research. Evidence & Policy: A Journal of Research,
Debate and Practice 8: 285–309.
Di Stefano, J., Fidler, F. & Cumming, G. 2005. Effect size esti-
mates and confidence intervals: an alternative focus for the
presentation and interpretation of ecological data. In: Burke,
A.G. (ed.) New trends in ecology research, pp. 71–102. NOVA
Publishers, New York, NY, US.
Diekmann, M. 2003. Species indicator values as an important

32. tool in applied plant ecology: a review. Basic and Applied Ecol-
ogy 4: 493–506.
Dwan, K., Altman, D.G., Arnaiz, J.A., Bloom, J., Chan, A.-W.,
Cronin, E., Decullier, E., Easterbrook, P.J., Von Elm, E., (. . .)
&Williamson, P.R. 2008. Systematic review of the empirical
evidence of study publication bias and outcome reporting
bias. PLoS ONE 3: e3081.
Falagas, M.E. & Alexiou, V.G. 2008. The top-ten in journal
impact factor manipulation. Archivum Immunologiae et Thera-
piae Experimentalis 56: 223–226.
Fanelli, D. 2012. Negative results are disappearing from most
dis-
ciplines and countries. Scientometrics 90: 891–904.
Fang, F.C. & Casadevall, A. 2011. Retracted science and the
Retraction Index. Infection & Immunity 79: 3855–3859.
Ferriman, A. 2007. BMJ readers choose the “sanitary
revolution”
as greatest medical advance since 1840. British Medical Jour-
nal 334: 111.2.

33. Fidler, F., Cumming, G., Burgman, M. & Thomason, N. 2004.
Statistical reform in medicine, psychology and ecology.
Journal of Socio-Economics 33: 615–630.
Gilbert, R., Salanti, G., Harden, M. & See, S. 2005. Infant
sleep-
ing position and the sudden infant death syndrome: system-
atic review of observational studies and historical review of
recommendations from 1940 to 2002. International Journal of
Epidemiology 34: 874–887.
Giner-Sorolla, R. 2012. Science or art? How aesthetic standards
grease the way through the publication bottleneck but under-
mine science. Perspectives on Psychological Science 7: 562–
571.
Hansen, H.F. & Rieper, O. 2009. The evidence movement: the
development and consequences of methodologies in review
practices. Evaluation 15: 141–163.
Hattie, J. 2009. Visible learning: a synthesis of over 800 meta-
analyses
relating to achievement. Routledge, New York, NY, USA.

34. Hochberg, M.E., Chase, J.M., Gotelli, N.J., Hastings, A. &
Naeem,
S. 2009. The tragedy of the reviewer commons. Ecology Letters
12: 2–4.
Hopewell, S., Loudon, K., Clarke, M.J., Oxman, A.D. & Dicker-
sin, K. 2009. Publication bias in clinical trials due to statistical
significance or direction of trial results. Cochrane Database of
Systematic Reviews 2009, Issue 1. Art. No.: MR000006.
Humbert, J.-Y., Pellet, J., Buri, P. & Arlettaz, R. 2012. Does
delaying the first mowing date benefit biodiversity in mead-
owland? Environmental Evidence 1: 9.
Ioannidis, J.P.A. 2005. Why most published research findings
are false. PLoS Medicine 2: e124.
Jackson, M.B. 2009. AoB PLANTS: origins and features. AoB
PLANTS 1: 2.
Kent, M. & Ballard, J. 1988. Trends and problems in the
applica-
tion of classification and ordination methods in plant ecol-
ogy. Vegetatio 78: 109–124.

35. Kettenring, K.M. & Adams, C.R. 2011. Lessons learned from
invasive plant control experiments: a systematic review and
meta-analysis. Journal of Applied Ecology 48: 970–979.
Knight, A.T. 2006. Failing but learning: writing the wrongs
after
Redford and Taber. Conservation Biology 20: 1312–1314.
Koricheva, J., Gurevitch, J. & Mengersen, K. 2013. Handbook
of
meta-analysis in ecology and evolution. Princeton University
Press, Princeton, NJ, US.
Kotze, D.J., Johnson, C.A., O’Hara, R.B., Veps€al€ainen, K. &
Fow-
ler, M.S. 2004. Editorial: the journal of negative results in
ecology and evolutionary biology. Journal of Negative Results:
Ecology & Evolutionary Biology 1: 1–5.
Kueffer, C., Niinemets, €U., Drenovsky, R.E., Kattge, J.,
Milberg,
P., Poorter, H., Reich, P.B., Werner, C., Westoby, M. &
Wright, I.J. 2011. Fame, glory and neglect in meta-analyses.
Trends in Ecology & Evolution 26: 493–494.

36. Lindenmayer, G. & Likens, G.E. 2013. Benchmarking open
access science against good science. Bulletin of the Ecological
Society of America 94: 338–340.
Masing, V. 1994. Approaches, levels and elements of vegetation
research. Folia Geobotanica et Phytotaxonomica 29: 531–541.
McCloskey, D.N. & Ziliak, S.T. 2009. The unreasonable
ineffec-
tiveness of Fisherian “tests” in biology, and especially in
medicine. Biological Theory 4: 44–53.
Memmott, J., Cadotte, M., Hulme, P.E., Kerby, G., Milner-
Gulland, E.J. & Whittingham, M.J. 2010. Putting applied
ecology into practice. Journal of Applied Ecology 47: 1–4.
Milberg, P., Akoto, B., Bergman, K.-O., Fogelfors, H., Paltto,
H. &
T€alle, M. 2014. Is spring burning a viable management tool for
species-rich grasslands? Applied Vegetation Science 17: 429–
441.
Moonesinghe, R., Khoury, M.J. & Janssens, A.C.J.W. 2007.
Most published research findings are false: but a little replica-
tion goes a long way. PLoS Medicine 4: e28.

37. Newton, A.C., Stewart, G.B., Myers, G., Diaz, A., Lake, S.,
Bullock, J.M. & Pullin, A.S. 2009. Impacts of grazing on low-
land heathland in north-west Europe. Biological Conservation
142: 935–947.
Nutley, S.M., Walter, I. & Davies, H.T.O. 2007. Using
evidence: how
research can inform public services. The Policy Press, Bristol,
UK.
Pautasso, M. & Sch€afer, H. 2010. Peer review delay and
selectiv-
ity in ecology journals. Scientometrics 84: 307–315.
Ridley, J., Kolm, N., Freckelton, R.P. & Gage, M.J.G. 2007. An
unexpected influence of widely used significance thresholds
on the distribution of reported P-values. Journal of Evolution-
ary Biology 20: 1082–1089.
Rojek, J., Alpert, G. & Smith, H. 2012. The utilization of
research
by the police. Police Practice and Research 13: 329–341.
Rothman, K.J. 1998. Writing for epidemiology. Epidemiology 9:
333–337.

38. Scherer, R.W., Langenberg, P. & von Elm, E. 2007. Full
publica-
tion of results initially presented in abstracts. Cochrane Data-
base of Systematic Reviews , Issue 2. Art. No.: MR000005.
607
Applied Vegetation Science
Doi:10.1111/avsc.12114 © 2014 International Association for
Vegetation Science
P. Milberg Evidence-based vegetation management
Schoenfeld, J.D. & Ioannidis, J.P.A. 2013. Is everything we eat
associated with cancer? A systematic cookbook review.
American Journal of Clinical Nutrition 97: 127–134.
Simonetti, J.A. 2011. Conservation biology in Chile: Are we
fulfilling our social contract? Revista Chilena de Historia
Natural 84: 161–170.
Statzner, B. & Resh, V.H. 2010. Negative changes in the
scientific
publication process in ecology: potential causes and conse-
quences. Freshwater Biology 55: 2639–2653.

39. Stewart, G.B., Bayliss, H.R., Showler, D.A., Sutherland, W.J. &
Pullin, A.S. 2009. Effectiveness of engineered in-stream struc-
ture mitigation measures to increase salmonid abundance: a
systematic review. Ecological Applications 19: 931–941.
Vetter, D., Rucker, G. & Storch, I. 2013. Meta-analysis: a need
for well-defined usage in ecology and conservation biology.
Ecosphere 4: 74.
Wellcome Trust. 2003. Economic analysis of scientific research
publishing. A report commissioned by the Wellcome Trust.
Avail-
able at www.wellcome.ac.uk/About-us/Publications/Publi
cationsA-Z/ Accessed 28 October 2013.
Applied Vegetation Science
608 Doi:10.1111/avsc.12114 © 2014 International Association
for Vegetation Science
Evidence-based vegetation management P. Milberg