Azathioprine

Russell Dean Anderson, MD

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/russell-dean-anderson-md

If the information is not readily available spasms vs spasticity cheap 50mg azathioprine overnight delivery, conduct desk reviews and field-level risk assessment to identify areas and populations at risk (see Annex 6C for risk and capacity assessment) spasms eye purchase azathioprine on line. Estimate the number of people that may be affected in case of an outbreak (see Section 3 muscle relaxant injection for back pain discount azathioprine american express. Step 3: If a preparedness and response plan muscle relaxant tinnitus order azathioprine in united states online, including communications quinine muscle relaxant mechanism azathioprine 50mg mastercard, exists muscle relaxant dosage cheap azathioprine 50 mg online, review the plan and update it accordingly. Analyse the capacity of the partners and these services for preparedness and response to an outbreak. Step 6: Identify national staff to be trained in various disciplines, with an estimated schedule, or those that should be trained according to the most affected areas. Step 7: Estimate the current availability of supplies and supply needs based on a risk analysis, to include the existing procurement system and the logistics for storage and distribution. Step 8: Estimate the available funds and funding sources for prevention, preparedness and response. See Annex 6E for preparedness and response logframe and examples of objectives, expected results, outcomes, indicators and activities. In countries vulnerable to cholera, preparedness plans should also be in place at sub-national levels, by region, district or equivalent area, depending on the size and structure of the country. The plans should be based on the framework established in the national plans, but focussed on the particular needs and priority areas for intervention for the specific context. Because cholera crosses borders, cholera preparedness and response plans may also be needed at a higher regional level, i. Refer to Annex 6F for a listing of key personnel required to address cholera, the key skills they require for their jobs and the topicswhich need to be included in their training. Job descriptions and back-up support It is important to have simple job or task descriptions for all staff, including any outreach workers (voluntary or paid) in order to clearly define what is expected of them. Outreach staff should also be clearly informed of where they can obtain help and advice. The preparedness and response plan must identify the key personnel required for the response and 41 include job description templates or terms of reference for anticipated posts. It is very difficult to build capacity once an outbreak begins because personnel often work long, erratic hours and experience exhaustion and limitations to their ability to leave their posts. Nevertheless, during epidemics in places where cholera has not existed or occurred for some time, undertaking capacity building during the outbreak will be unavoidable. The right hand column identifies additional resources on capacitybuilding needs, examples of existing training materials and case study examples. Supplies / stockpiles the pre-positioning of preparedness supplies/stockpiles for cholera can lead to greater efficiency in response. Remember that consumables within the kits have use-by-dates and may need replacement if the stocks are held for some time. Logistics plans will be required for moving supplies to the main warehouse and to strategic storage locations. Each supply location should set reorder points based on estimated usage rates and estimated resupply times, and then adjust those re-order points based on operational success. Disposal options will also be required in consultation with the Ministry of Health or the responsible authority (such as the Environment Agency). If the stocks or equipment are held for some time, the consumables will need replacing and old items will require disposal. This request should be made as soon as cholera has been identified (whether it has been declared or when the government has not declared it as cholera, but has acknowledged that there is an outbreak of an acute watery diarrhoeal disease). Smaller scale interventions, supported by civil society and the private sector are increasingly involved. Specific fundraising for preparedness activities may be more challenging in endemic contexts where cholera outbreaks are usually small or medium in size. Funds are likely to be more accessible in the periods after a large-scale outbreak. Overview of Chapter 3 this chapter highlights the two main areas of communication that play a central role in successful prevention, preparedness and response efforts with respect to cholera outbreaks: 1) communication for development (C4D) which focuses on local-level advocacy and behaviour and social change issues, and 2) media relations, advocacy and institutional communication. Introduction to communication for cholera Successfully controlling an outbreak of cholera requires the collaboration of many different stakeholders and the implementation of a variety of different interventions. Because of the cross-cutting nature of communication, this Toolkit includes a specific chapter as well as numerous references to the role of communication throughout. The table below provides an overview of the sections and chapters that relate directly to communication. Communication is not just about providing information to affected communities; it should also facilitate participatory discussion in order to trigger community action and contribute to building rapport between communities and service providers. Finally, communication should advocate that government decision makers generate more resources and create better policies to fight against cholera. Communication must be evidence-based, results-oriented and delivered first, fast and from the field in a consistent, compelling and coherent way, as per the right of communities to be informed. See Annex 7A for a review of various types of communication strategies used to prepare and respond to cholera outbreaks. How to develop a of a communication strategy and plan the development of an evidence-based, inter-sectoral communication strategy and plan (media and C4D) is a 48 vital first step in ensuring effective communication. When planning communication, it is critical to distinguish among participant groups to better focus the communication interventions. However, if the goal is to talk with potential donors, it is important to work with the international media. Communication approaches for urban and rural contexts may also vary, as might the ways to communicate with duty-bearers (service providers) and rights-holders (children, families and communities). Steps in the development of a communication plan Communication planning is an on-going process that needs to be updated regularly in light of on-going assessment and feedback from communities and key participant groups, particularly those from high-risk populations. Further information on how to undertake the steps can be found in the Key Resources listed at the end of this 19 chapter. Cross/Crescent volunteers Hence, a robust M&E plan should be in place from the onset of activities. When the outbreak occurs Key players / partners Step 4: Reflect, update and act on the intersectoral communication plan that has been developed as a preparedness measure. This communication can be done through weekly radio (including community radios) and/or television broadcasts: by using print media or via interpersonal Co-ordination task force communication channels such as community dialogues, theatre groups, local Media spokesperson leaders, etc. Societies partners Obtain updates on health information from the surveillance system and Outreach workers other sources to ensure that unreached populations are identified and Media organisations targeted as soon as possible. In these countries/areas, as part of cholera prevention, cholera related messages should be mainstreamed within regular development programmes. Such activities may include the following: Provide feedback to and hear feedback from affected communities and all partners on the results of the response communication activities, and preparedness for future outbreaks. Media guides that detail the status of mass media communications have also been developed for a variety of countries and are available from the following website: infoasaid. Identifying communication channels the communication assessment will provide clues for identifying the best channels according to the current situation and the context. See Annex 7D for a description of the different types of communication activities and channels used in cholera responses. Working with the media / crisis communication Develop connections with national and sub-national media and with the media departments of the Ministry of Information and Communication and local radio stations before the emergency will mean that opportunities for collaboration and coherence of approach are identified early. If community radio stations are present in the country, they often play an important role in informing and generating dialogue with local communities. The dialogue and sharing of information with affected communities and families is essential for cholera control efforts. News of a cholera outbreak can incite high emotions within a society and can inflame underlying tensions. It should be a high priority of those involved in cholera control to ensure that a calm analysis of the situation is undertaken to provide the appropriate basis for good decisions and to ensure frequent and effective communication with those who have the ear of the public. The first step in ensuring constructive communication with an external audience is to have one skilled designated spokesperson who can represent the situation on behalf of the cholera control authorities. Authority should be delegated for holding regular media conferences and issuing regular releases of information. While there may be situations where some data should be kept confidential, these are rare; in general information should be shared with the public when it is available, although care should be taken to make it comprehensible to a lay audience. Consider preparing media briefings with key, up-to-date information to be distributed during the press conference. All journalists should leave the press conference with the same information, including numbers, statistics and response. These are often used in communicating details of elections or school arrangements. In Pakistan, these channels were used for advocacy around the International Year of Sanitation and Global Hand-Washing Day. In Tanzania, the government regularly announces outbreak news during a regular weekly slot on one radio station. Key information on how to prevent cholera and where to go for treatment, as well as information on the status of the outbreak and planned activities, should be broadcast as a public service. Where traditional media such as street theatre, interactive film shows or music are used, efforts should also be made to provide communities with a chance to comment and ask questions during or after the show. These stations can be strong allies with respect to cholera prevention and response. They allow broad national or global social movements to form through on-line affiliations that connect offline groups and individuals and allow them to find each other and collaborate. They can be useful communication channels for cholera preparedness, response and recovery. Tip: Communicating with the media Include media communication in your action plan Be assertive in preventing, minimizing, or countering false rumours. Rumours are rife during cholera outbreaks and cultivating a constructive relationship with the mass media, preferably before an outbreak, 52 can go far to prevent their potentially destructive impact. All those involved in cholera prevention and response should be providing consistent information to participant groups in order to avoid confusion and misunderstanding. Different agencies do not necessarily have to communicate in the same way or use the same message, but they must aim to achieve the same action or result. Front line health workers including other service providers and community outreach workers at the community level health care facilities need clear guidelines on key health messages and behaviour. Tip: Behaviour and social change communication Dialogue and discussion can be very effective in identifying practical actions and motivating groups or individuals, but both mass media and interactive methods should be employed. Interactive drama/theatre groups, video sessions and community dialogue initiatives as well as mass media channels are likely to be more effective at promoting behaviour and social change. Cholera preparedness plans should attempt to review any existing material and where possible adapt these to the cholera response. In this case, if boiling is not feasible, include instructions about other methods such as chlorine liquid, tablets or powder, or water filters, and where these can be obtained. Distribution should include information and training on how to use materials supplied as well as monitoring and support for consistent use.

Serum: Acute and convalescent phase sera are needed to diagnose viral disease and potentially screen for the presence of staphylococcal exotoxin and any potential antibody to such a toxin skeletal muscle relaxants quiz cheap azathioprine online master card. Please indicate on any specimens that are sent to the State Laboratory of Hygiene that you are interested in ruling out toxic shock syndrome spasms knee purchase azathioprine cheap. Patients in our series placed on specific antistaphylococcal regimens have demonstrated clinical improvement muscle relaxant lotion buy azathioprine 50 mg low cost, but it is not clear how significant antistaphylococcal therapy is relative to other components of supportive therapy spasms vs fasciculations generic azathioprine 50 mg without a prescription. Full attention to ruling out all clinical possibilities and maintaining full supportive management is stressed muscle relaxant recreational buy azathioprine 50 mg with amex. Jeffrey Davis (Wisconsin Division of Health quadricep spasms generic 50mg azathioprine, Bureau of Prevention) 608/266-1251 or Dr. William Taylor 608/266-1251 or 608/266-9783 as soon as you become clinically aware of any potential case of toxic shock syndrome. If you recall seeing a similar case at any point in time in the past we would greatly appreciate learning of such cases. Please feel free to call if you have any questions pertaining to any facet of this syndrome. Further information as it becomes available will appear in the Wisconsin Epidemiology Bulletin. In February 1980, while planning an initial case control study, I called Jim Todd, the chief of pediatric infectious diseases at the University of Colorado Medical School, to discuss our findings. These included 25 females with a mean age of 20 years of whom 20 had vaginitis and 10 males with a mean age of 11 years of whom 7 had focal bacterial infections. He could recall only one potential recurrence, and he agreed that a case control study to examine risk factors was needed. By April, we concurred on the case definition criteria, which became very durable in its application over time (Table 5-1). We received numerous physician generated and selfreports of potential cases and laboratory specimens. Clinical and laboratory data were systematically collected using a case report form that I had generated. In addition, he stored paired samples of sera from case patients for future testing. It is always critical to anticipate future testing, and storing isolates and paired sera is most valuable. This difference can be explained in part by rapid dissemination of extensive clinical and epidemiologic information to a broad group of stakeholders who included physicians, infection control practitioners, public health partners, and the media. The letter to physicians was particularly important because it had detailed description of the illnesses and known risk factors, which facilitated rapid disease recognition, including recognition of milder cases. These materials also included detailed recommendations for patient management, which facilitated rapid and appropriate clinical management that in turn enhanced outcomes and reduced mortality. These controls had to be not more than 2 years of age younger or older than their respective case patients and had to be nonpregnant at the time of survey administration. Based on information from case reports and my phone conversations with case patients, their physicians, and Joan, I created a survey instrument. This survey was used to examine potential risk factors and host factors and hypotheses, including demographic features (marital status, other), characteristics of menstruation (flow duration and intensity), catamenial products (tampons, napkins, pads) used during menstruation (including type and brand, deodorant containing or not), exertion and its extent, birth control and contraceptive methods used, and presence of herpes infection. In late spring, we balanced the concern about the need for a sufficiently large population to assess adequately differences in the use of commonly used products with the need for important information on risk factors of a serious widespread illness. Our study inclusive of cases with onsets through June 30, 1980, was published in the New England Journal of Medicine. We found the median time from the onset of menses to the onset of illness was 3 days (mode, 2 days; range, 0 to 9 days). Although the minority population proportion in Wisconsin was relatively small at the time, this complete absence of minorities among the case patients was a striking finding. We also found the practice of contraception (any method) was protective (9 of 35 cases vs. We waxed eloquently on the meaning of this finding in our discussion that included the difference in marital status (34% of case patients were married vs. We also discussed the physiology of oral contraceptives but did not understand its role. Although we were working extraordinary hours for such a lengthy time and would expect to generate new information, we were amazed at the rapidity of the emergence of so much new information. All 50 case patients with onsets during menstruation used tampons compared to 86% of 50 controls. In a separate, smaller case control study conducted in Utah by Bob Latham, Mark Kehrberg, and colleagues, all 12 cases and 80% of 40 neighborhood-matched controls used tampons. Rely tampons were a recently introduced and rather unconventional product that had rapidly been gaining market share. I recalled receiving free samples of Rely in the mail at my home on two occasions, which was unusual because I was single at the time. Mike and Bob Gibson and Jack Mandel (both faculty in the University of Minnesota system) were deft methodologists, and Bob rapidly generated complex computer-based analyses using a database incorporating data from the finely tuned 16-page study questionnaire and also proprietary tampon fluid capacity and chemical composition data for all brand styles of tampons in the marketplace through early September. With the assistance of legal council, Mike worked with representatives of each of the tampon manufacturers to procure these data, and to their credit, the companies willingly provided it. Those having neither factor had the least risk of recurrence, and those having either factor but not the other had an intermediate risk of recurrence. Because of widespread publication of this finding, the case-comparison studies had problems due to differential ascertainment and recall bias. However, the number of cases among women was so great and the relation with tampon use so marked that unreasonable assumptions are necessary if the results are to be attributed to these biases. These studies show the power of epidemiologic methods, even given the unfavorable circumstance of an uncommon condition, associated with a common practice. Peak rates of nearly 15 cases per 100,000 menstruating women per year in Wisconsin were noted among women 15 to 19 years old who were regular users of tampons (Figure 5-1). There were over 100 reported deaths, and the case fatality rate decreased from 10% before 1980 to 5% in 1980 and 3% in 1981 and 1982. Toxic-shock syndrome: Epidemiologic features, recurrence, risk factors and prevention (Fig 2). I experienced unanticipated intervals of tampon burnout, but I learned more about tampons in 1 year than I ever expected to know during a lifetime. Lyme disease in Wisconsin: epidemiologic, clinical, serologic and entomologic findings. Toxic-shock syndrome: epidemiologic features, recurrence, risk factors and prevention. Pathogenic mechanisms of the hypocalcemia of the staphylococcal toxic-shock syndrome. Toxic-shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases. Risk factors for development of toxic shock syndrome: association with a tampon brand. A new staphylococcal enterotoxin, enterotoxin F, associated with toxic-shock syndrome Staphylococcus aureus isolates. Identification and characterization of exotoxin from Staphylococcus aureus associated with toxic shock syndrome. Seroprevalence of antibody to staphylococcal enterotoxin F among Wisconsin residents: implications for toxic-shock syndrome. Development of serum antibody to toxic-shock toxin among individuals with toxic-shock syndrome in Wisconsin. Longterm effects of toxic shock syndrome in women: sequelae, subsequent pregnancy, menstrual history and long-term trends in catamenial product use. Recovery of staphylococcal enterotoxin F from the breast milk of a woman with toxic-shock syndrome. I stayed for 3 years but left when I had the opportunity to do an infectious diseases fellowship. It was a bit strange to be working on infectious diseases at a time when the public health community seemed to feel that many of the problems posed by infectious diseases had been solved, at least in the developed world. We had vaccines for most of the childhood infections and a broad range of antibiotics available to treat bacterial and even some viral diseases. Robert Petersdorf, a very eminent infectious diseases physician from the University of Washington, in which he argued that the demand for infectious diseases specialists was likely to diminish. First, was this really a new disease, or had similar cases occurred in the past without being reported These questions led to fundamental epidemiologic steps that are essential to ask as one begins to investigate a possible outbreak. Determine the extent of the problem by searching for additional cases within and outside of the area of the initial report. More thoroughly examine the problem through case investigation, and consider performing a risk factor analysis to identify whether information can be learned that could create a prevention strategy to decrease the extent of or terminate the outbreak. A record review revealed that almost all previous pentamidine requests had been for persons with an obvious cause of immune suppression. Beginning in the second half of 1980, however, a few requests had been received for persons fitting the profile of the Los Angeles cases. The answers to questions two and three came soon after the report from Los Angeles. I was so worried that I would forget the strange name of the disease that I wrote it on a slip of paper and put it in my wallet so that I could discuss it when I returned to Atlanta. We distributed the case definition to health departments and major teaching hospitals. By the end of August 1981, over 100 cases meeting the definition had been reported. Physicians seeing cases at one hospital were often unaware that similar patients were being seen at other hospitals in the same city. To break down these communication barriers, he established monthly meetings at the health department, at which clinicians from all of the major New York City hospitals would come to discuss their cases and hear updates from health department staff. I was asked to go to San Francisco, and I spent several days talking to patients cared for at University of California, San Francisco. In speaking with the men who were able to talk, it became apparent that they were highly sexually active and had used a variety of recreational drugs. With the permission of the manager, we interviewed customers about their use of poppers. We subsequently learned that poppers could also be bought in gay bars and bookstores in unlabeled bottles. The study would examine a wide range of possible causes but would focus on infectious and environmental risk factors. Because of the sensitive nature of the questions, we decided to conduct all of the interviews in person. Although the men we interviewed could have had many reasons to distrust us, I was very impressed by how open they were in discussing the most intimate details of their lives. We did the interviews in our hotel rooms, creating much puzzlement among the desk clerks who must have wondered why all these young men were asking to see us. Taking no particular precautions (we did not wear gloves), we also drew blood from these men in our rooms. In retrospect, we were very foolish, although this was an accepted practice in medical facilities at the time. He wanted to interview the men to confirm these rumors but had never done this sort of interviewing and needed help. In just a few days, Darrow and Auerbach were able to confirm the sexual links between these cases. As the investigation expanded, a total of 40 patients living in 10 North American cities could be linked by sexual contact. The clinical spectrum of illness began to expand to conditions beyond those initially identified. Almost all of the Haitians were young men; those interviewed all denied homosexual activity. The case total in the United States was approaching 800, with a mortality rate of about 40%. Although cases were still concentrated in New York City, San Francisco, Los Angeles, Newark, and Miami, other cities were beginning to report cases. Arthur Ammann, a pediatric immunologist at University of California, San Francisco, was caring for a 20-month old infant with unexplained severe immunodeficiency. The child had received multiple transfusions shortly after birth to treat erythroblastosis fetalis (a condition that results from a blood group incompatibility between mother and fetus). Although initially reported with no known risk factors, subsequent investigation by David Auerbach determined that the donor was a homosexual man. Furthermore, the source of transmission could be a person who had not yet developed the disease, implying that the agent could be carried asymptomatically.

Survival times: A few hours on dry surfaces 1-35 days at 2-4oC (ice box temperature) Note: Consideration of the impact of climate change on cholera risk: 3 1-14 days at room temperature Climate change increases the risk of cholera in several ways: (1) the growth 5-24 days in well water 4 of bacteria muscle relaxant egypt purchase azathioprine line, like Vibrio vulnifcus and Vibrio cholerae (non-O1 and non-O139) spasms in your stomach purchase generic azathioprine online, 1-2 years in warm coastal waters muscle relaxant amazon purchase azathioprine 50mg free shipping, estuaries in the sea and brackish waters substantially increases at higher temperatures 28-35 days in ice cubes in an ice chest 5 and (2) severe disaster events damage water and sanitation infrastructure 1-2 days on metal utensils and create conditions conducive to faecal-oral contamination and higher Possibly over 6 months in frozen seafood spasms on right side of stomach 50mg azathioprine with amex. Both warmer sea surface temperatures and extreme Survival limits: 7 weather are infuenced by El Nino Southern Oscillation variability muscle relaxant reversal agents cheap azathioprine 50 mg without a prescription. Based on this evidence muscle relaxant high 50 mg azathioprine visa, multiple global collaborative projects are working to Reservoirs for multiplication; growth and doubling times: establish cholera early warning systems using climatic data and models. Examples of how age and gender may affect susceptibility to infection: Ministry of Health and Population in Haiti/U. Alerts must be verifed within 24 and to adjust response interventions based on changing hours of notifcation. Response speed is critical; suppression 28 29 of information, failure to recognize an outbreak or slowness to respond can It is not necessary, in the midst of an outbreak, to confrm the status of every result in an epidemic of greater magnitude and in the preventable loss of life. A multi-disciplinary Outbreak Investigation team (rapid response team) 1 should deploy immediately to study the occurrence. The the national response plan, assessing resource needs, distributing team can also use the opportunity to make a quick assessment of Health messages to the community, etc. During this investigation the team will: prevention, preparedness and response interventions. Once an outbreak has been confrmed, diagnosis of See Annex 3D for a sample alert register, and Annex 3E for a patients can rely on symptoms alone, i. The case defnition and instructions on where and and transmitted to the central level daily (if early in the outbreak) and weekly. Personnel Data can also be entered into a spreadsheet for quick interpretation of trends at health facilities at all levels of the health system should be taught in numbers and pictorially through graphs. It is important to employ a variety of means to actively review information obtained from 32 33 communities. Weekly data can also be described by age or gender reports, blogs, and any other unoffcial information sources. Each facility should weekly or monthly, depending on the progression of the outbreak. It should be monitored at the lowest administrative level to update response interventions and at national or Action 4C: Create epidemiologic maps regional levels to support advocacy and fundraising, predict spread, estimate Maps are a useful tool to determine the geographic origin and likely path resource needs and signal neighbouring countries of epidemic proximity. Spot maps or hand-drawn maps can show where, how and why Data should be analysed and reported using a mix of numbers, graphs and the outbreak is moving and the locations of cases, roads, water sources maps to describe: and health facilities in more than larger country-level maps. Assessments of cholera See the information in Annex 3F on line-listings for more information on transmission from particular bodies of water, food outlets or other sources 6 understanding person, place and time from collected data. Additional studies, including laboratory tests and environmental studies, can be conducted as necessary, although they can be time and 9 interventions. The analysis of these trends should be conducted at the lowest administrative level to allow immediate adjustment of the prevention resource consuming and the capacity limited in low-income countries. Information for daily reporting of cases and deaths can be drawn from alerts and facility-reported data from line 3. In the longer term, eliminating cholera 9 7 transmission will require sustained efforts on making water and sanitation services accessible and used, appropriate hygiene practices adopted (which 8 usually requires changing personal and social behaviours) and health care services accessible and of good quality. Additional See Annex 4A for: interventions will be needed in formulating appropriate responses. Both offer the major advantage of being relatively easy to administer in a short time and of to outbreaks. They are intended to prevent the spread of cholera and to depending more reliably on functioning health systems and their partners reduce mortality through preventing infection. Increasing emphasis and 1 bringing additional resources to existing diarrheal disease programs so they can scale up should be part of any cholera prevention strategy. The speed of response has signifcant bearing on the management and impact of an outbreak. It also considers the meetings, sources of information and the importance of information management. Activities that will lead to the prevention of cholera (and infectious diarrhoeal diseases of all varieties) over the longer term should be undertaken as part of developmental efforts to build systems, structures and services. Irrespective of format and name, the core functions 1 meeting timings and restricting reports to a needs basis. Membership composition of a national cholera task force It is always benefcial to involve and engage civil society, the Red Cross-/Red A national cholera task force should be broadly representative. A typical task force might include: In a country that has experienced large-scale outbreaks, the existence of a stand-alone cholera task force is more likely. For cholera endemic countries, 56 57 Suggested members of a typical cholera national Membership composition may change by context. These guides community media such as 10 radio associations provide a range of useful information for supporting government-led sectoral and inter-sectoral co-ordination efforts. Some of them can be operantional all the time, some of them can be activated for outbreak response only; some areas might be merged in one committee, and more committees can be created as per the existent needs Sub-national coordination platform Sub-national coordination platform Coordination between local authorities Province/District A Province/District B for cross-border intervention 6 Challenges presented by national cholera task forces 5. However, the high level of commitment required for participation in the task force is on prevention and preparedness. Actions points arising from the meeting should be to emerging disseminated as fast as possible and followed up. During outbreaks in Peru (1991) and in Tanzania, Kenya, Uganda and limitations. Since cholera the ground are often working hard to do their best to respond labeling appears to trigger signifcant reactions, non-declaration may be within the limitations. This includes the need to respond promptly and use mass media to inform large populations with key information. Also, highlight the likely the stakeholders outlined in the following table may be involved in cholera impacts if the outbreak becomes extensive, including the costs prevention, preparedness and response. The range of stakeholders involved to the country, and share examples of other large outbreaks. Responders to cholera crises need to understand both the value and limitations of the data. Information management in the context of a cholera outbreak involves the collection, processing, analysis and dissemination of information. Outbreak information needs to be accessible to everyone involved in the 9 preparedness and response efforts in an appropriate and timely manner. The co-ordination mechanisms play a key role in making dissemination effective, 10 manageable and useful. It is particularly important to undertake preparedness outbreak, including who will do what, where, and when. Co-ordination, institutional framework these elements become actions in the process of preparedness. The order and information management of the steps that need to be taken will vary according to the existing level of (Section 6. Cholera preparedness and Policies, strategies, guidelines, 1 standards and standard response plan operating procedures 2 6. This meeting is a good opportunity to defne/ reassess the cholera co-ordination and information management system. The plans should be based on the health coverage and any other contextual information such as seasonal data, 1 framework established in the national plans, but focussed on the particular confict updates, locations of camps for refugees and displaced persons, etc. Estimate the number of Because cholera crosses borders, cholera preparedness and response 3 people that may be affected in case of an outbreak (see Section 3. Building the capacity of personnel working in cholera response should 4 be prioritised as an essential element of preparedness. It is very diffcult Job descriptions and back-up support 5 to build capacity once an outbreak begins because personnel often work It is important to have simple job or task descriptions for all staff, including long, erratic hours and experience exhaustion and limitations to their any outreach workers (voluntary or paid) in order to clearly defne what is ability to leave their posts. Because cholera outbreaks can develop and spread very quickly, it is imperative to deploy personnel as rapidly as possible. Remember that Capacity building needs consumables within the kits have use-by-dates and may need replacement 2 assessment Identifcation of if the stocks are held for some time. Logistics plans will be required for moving supplies Supervision of trainees and to the main warehouse and to strategic storage locations. Disposal options 5 may have strategically placed warehouses which can be used will also be required in consultation with the Ministry of Health or the for strategic placement of supplies. For supplies being imported, customs clearance will need to be cholera-related health facilities, but are not as useful when negotiated. Prea decentralised response is required, as in rural areas that arrangements with customs authorities can help accelerate processing. If the required to cover the cost of the following activities (in addition to the costs 7 stocks or equipment are held for some time, the consumables of co-ordination, management, human resources and logistics): will need replacing and old items will require disposal. This request should be 10 purchase of pre-stocks; capacity mapping and needs assessment; capacity made as soon as cholera has been identifed (whether it has development; surveillance and early warning systems. It may also be possible to integrate cholera preparedness efforts into general emergency preparedness proposals in support of national disaster management efforts. Effective and strategic communication in varying forms (media and external relations, advocacy, hygiene promotion, behaviour change communication, communication for social change and social mobilisation, etc. The table below provides an overview of the to trigger community action and contribute to building rapport between sections and chapters that relate directly to communication. Finally, communication should advocate that government decision makers generate more resources and create better policies to fght against cholera. Additional activities related to communication and transfer of information within thisToolkit See Annex 7A for a review of various types of communication strategies used to prepare and respond to cholera outbreaks. Surveillance, outbreak investigation, epidemiological Chapter 3 data, monitoring and reporting 7. Further information on how to undertake the steps can be found in the Key Resources listed at the end of this chapter. Identify a media process and outcome), monitoring activities, spokesperson to be responsible. It is critical to closely 2 monitor activities and evaluate the impact of See the Co-ordination and communication when communication interventions. News of a cholera outbreak affected communities and all partners on can incite high emotions within a society and can infame underlying 2 the results of the response communication tensions.

Syndromes

• Jaundice
• T (thymus derived) lymphocyte count
• Halos around objects (yellow, green, white)
• Nervousness
• Do NOT apply pesticide sprays to items or areas touched by family members, such as furniture
• Medicine (antidote) to reverse the effects of the poison
• Narcolepsy does not respond to treatment, or you develop other symptoms
• If you have had a recent or past infection such as mononucleosis or viral hepatitis
• Irritability

If a plasma derivative such as antihemophilic factor muscle relaxant guidelines buy azathioprine 50 mg cheap, brinogen spasms behind knee discount azathioprine 50 mg amex, pooled plasma or thrombin is implicated spasms with ms cheap 50mg azathioprine with amex, withdraw the lot from use and trace all recipients of the same lot in a search for additional cases muscle relaxant at walgreens buy cheap azathioprine 50mg. Disaster implications: Relaxation of sterilization precautions and emergency use of unscreened blood for transfusions may result in an increased number of cases muscle relaxant causing jaundice generic azathioprine 50mg. Of chronically infected persons muscle relaxants for tmj purchase azathioprine online now, about half will eventually develop cirrhosis or cancer of the liver. Sexual and mother-to-child have been documented but appears far less efcient or frequent than the parenteral route. Chronic infection may persist for up to 20 years before the onset of cirrhosis or hepatoma. Routine virus inactivation of plasma-derived products, risk reduction counselling for persons uninfected but at high risk. However, these medications have signicant side-effects that require careful monitoring. International measures: Ensure adequate virus inactivation for all internationally traded biological products. In the former case the infection is usually self-limiting, in the latter it will usually progress to chronic hepatitis and delta hepatitis can be misdiagnosed as an exacerbation of chronic hepatitis B. Children may have a severe clinical course with usual progression to severe chronic hepatitis. Control of patient, contacts and the immediate environment, Epidemic measures, Disaster implications and International measures: See hepatitis B. The case-fatality rate is similar to that of hepatitis A except in pregnant women, where it may reach 20% among those infected during the third trimester of pregnancy. Diagnosis depends on clinical and epidemiological features and exclusion of other causes of hepatitis, especially hepatitis A, by serological means. Outbreaks of hepatitis E and sporadic cases occur over a wide geographic area, primarily in countries with inadequate environmental sanitation. Outbreaks often occur as waterborne epidemics, but sporadic cases and epidemics not clearly related to water have been reported. Natural infections have been described in pigs, chicken and cattle, particularly in highly endemic areas. Person-to-person transmission probably also occurs through the fecal-oral route, although secondary household cases are uncommon during outbreaks. Recent studies suggest that hepatitis E may in fact be a zoonotic infection with coincident areas of high human infection. Women in the third trimester of pregnancy are especially susceptible to fulminant disease. The occurrence of major epidemics among young adults in regions where other enteric viruses are highly endemic and most of the population acquires infection in infancy remains unexplained. Preventive measures: Provide educational programs to stress sanitary disposal of feces and careful handwashing after defecation and before handling food; follow basic measures to prevent fecal-oral transmission, as listed under Typhoid fever, 9A. Control of patient, contacts and the immediate environment: 1), 2) and 3) Report to local health authority, Isolation and Concurrent disinfection: See hepatitis A. Epidemic measures: Determine mode of transmission through epidemiological investigation; investigate water supply and identify populations at increased risk of infection; special efforts to improve sanitary and hygienic practices in order to eliminate fecal contamination of foods and water. Disaster implications: A potential problem where there is mass crowding and inadequate sanitation and water supplies. If cases occur, increased effort should be exerted to improve sanitation and the safety of water supplies. Reactivation of latent infection commonly results in herpes labialis (fever blisters, cold sores) manifested, usually on the face or lips, by supercial clear vesicles on an erythematous base that crust and heal within days. Reactivation is precipitated by various forms of trauma, fever, physiological changes or intercurrent disease, and may also involve other body tissues; it occurs in the presence of circulating antibodies, which are seldom elevated by reactivation. Severe and extensive spread of infection may occur in those who are immunodecient or immunosuppressed. Fever, headache, leukocytosis, meningeal irritation, drowsiness, confusion, stupor, coma and focal neurological signs may occur and are frequently referable to one or the other temporal region. The condition may be confused with other intracranial lesions including brain abscess and tuberculous meningitis. In women, the principal sites of primary disease are the cervix and the vulva; recurrent disease generally involves the vulva, perineal skin, legs and buttocks. In men, lesions appear on the glans penis or prepuce, and in the anus and rectum of those engaging in anal sex. Neonatal infections can be divided into 3 clinical presentations: disseminated infections involving the liver, encephalitides and infections limited to the skin, eyes or mouth. Only excretion at the time of delivery is dangerous to the newborn, with the rare exception of intrauterine infections. Primary infection in the mother raises the risk of infection from 3% to over 30%, presumably because maternal immunity confers a degree of protection. A 4-fold titre rise in paired sera in various serological tests conrms the diagnosis of primary infection; the presence of herpes-specic IgM is suggestive but not conclusive evidence of primary infection. The prevalence is greater (up to 60%) in lower socioeconomic groups and persons with multiple sexual partners. Both types 1 and 2 may be transmitted to various sites by oral-genital, oral-anal or anal-genital contact. In recurrent lesions, infectivity is shorter than after primary infection, and usually the virus cannot be recovered after 5 days. Preventive measures: 1) Health education and personal hygiene directed toward minimizing the transfer of infectious material. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Ofcial case report in adults not ordinarily justiable, Class 5; neonatal infections reportable in some areas, Class 3 (see Reporting). Patients with herpetic lesions should have no contact with newborns, children with eczema or burns, or immunodecient patients. Corticosteroids should never be used for ocular involvement unless administered by an experienced ophthalmologist. Acyclovir used orally, intravenously or topically has been shown to reduce shedding of virus, diminish pain and accelerate healing time in primary genital and recurrent herpes, rectal herpes and herpetic whitlow. The oral preparation is most convenient to use and may benet patients with extensive recurrent infections. However, mutant strains of herpes virus resistant to acyclovir have been reported. Valacyclovir and famciclovir are recently licensed congeners of acyclovir that have equivalent efcacy. This causes an ascending encephalomyelitis seen in veterinarians, laboratory workers and others in close contact with eastern Hemisphere monkeys or monkey cell cultures. After an incubation of 3 days to 3 weeks, there is acute febrile onset with headache, often local vesicular lesions, lymphocytic pleocytosis and variable neurological patterns, ending in death in over 70% of cases, 1 day to 3 weeks after onset of symptoms. Occasional recoveries have been associated with considerable residual disability; a few cases, treated with acyclovir, have recovered completely. During periods of stress (shipping and handling), they have high rates of viral shedding. Human illness, rare but highly fatal, is acquired through the bite of apparently normal monkeys, or exposure of naked skin or mucous membrane to infected saliva or monkey cell cultures. Prevention depends on proper use of protective gauntlets and care to minimize exposure to monkeys. All bite or scratch wounds incurred from macaques or from cages possibly contaminated with macaque secretions and that result in bleeding must be immediately and thoroughly scrubbed and cleaned with soap and water. Prophylactic treatment with an antiviral agent such as valacyclovir, acyclovir or famciclovir should be considered when an animal handler sustains a deep, penetrating wound that cannot be adequately cleaned, though it is not clear if this is as effective in humans as it is in rabbits. The appearance of any skin lesions or neurological symptoms, such as itching, pain, or numbness near the site of the wound calls for expert medical consultation for diagnosis and possible treatment. Detailed information is given for the infection caused by Histoplasma capsulatum var. Five clinical forms are recognized: 1) Asymptomatic; although individuals manifest skin test reactivity to histoplasmin, this reagent is no longer commercially available. Multiple, small scattered calcications in the lung, hilar lymph nodes, spleen and liver may be late ndings. The immunodiffusion test is the most specic and reliable of available serological tests. A rise in complement xation titres in paired sera may occur early in acute infection and is suggestive evidence of active disease; a titre of 1:32 or greater is suggestive of active disease. Detection of antigen in serum or urine is useful in making the diagnosis and following the results of treatment for disseminated histoplasmosis. Prevalence increases from childhood to 15; the chronic pulmonary form is more common in males. Outbreaks have occurred in endemic areas in families, students and workers with exposure to bird, chicken or bat droppings or recently disturbed contaminated soil. Histoplasmosis occurs in dogs, cats, cattle, horses, rats, skunks, opossums, foxes and other animals, often with a clinical picture comparable to that in humans. Person-to-person transmission can occur only if infected tissue is inoculated into a healthy person. Inapparent infections are common in endemic areas and usually result in increased resistance to infection. Preventive measures: Minimize exposure to dust in a contaminated environment, such as chicken coops and surrounding soil. Control of patient, contacts and the immediate environment: 1) Report to local health authority: In selected endemic areas; in many countries not a reportable disease, Class 3 (see Reporting). Epidemic measures: Occurrence of grouped cases of acute pulmonary disease in or outside of an endemic area, particularly with history of exposure to dust within a closed space (caves or construction sites), should arouse suspicion of histoplasmosis. Suspected sites such as attics, basements, caves or construction sites with large amounts of bird droppings or bat guano must be investigated. Possible hazard if large groups, especially from nonendemic areas, are forced to move through or live in areas where the mould is prevalent. Infection, though usually localized, may be disseminated in the skin, subcutaneous tissue, lymph nodes, bones, joints, lungs and abdominal viscera. Disease is more common in males and may occur at any age, but especially in the second decade of life. In heavy infections, the bloodletting activity of the nematode leads to iron deciency and hypochromic, microcytic anemia, the major cause of disability. Children with heavy long-term infection may have hypoproteinemia and may be retarded in mental and physical development. Infection is conrmed by nding hookworm eggs in feces; early stool examinations may be negative until worms mature. Species differentiation requires microscopic examination of larvae cultured from the feces, or examination of adult worms expelled by purgation following a vermifuge. Both Necator and Ancylostoma occur in many parts of Asia (particularly southeastern Asia), the South Pacic and eastern Africa.

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