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The committees earlier report (Institute of Medicine, 2000) recommends that health care organizations and the professionals affiliated with them make continually improved patient safety a declared and serious aim by establishing patient safety programs with a defined executive responsibility. That report further recommends that patient safety programs: (1) provide strong, clear, and visible attention to safety; (2) implement nonpunitive systems for reporting and analyzing errors within their organizations; (3) incorporate well-understood safety principles, such as standardizing and simplifying equipment, supplies, and pro cesses; and (4) establish interdisciplinary team training programs, such as those involving simulation, that incorporate training designed to improve and maintain skills, as well as improve communication among team members. Chapter 5 of this report examines some design principles that organizations can apply to im prove safety. Rule 7: Need for Transparency the health care system should be uncompromising in its defense of patient confidentiality, a matter of great national concern. But the pursuit of confidenti ality is not a reason for hiding the systems performance from those who depend on the system for care. This new rule calls for health systems to be accountable to the public; to do their work openly; to make their results known to the public and professionals alike; and to build trust through disclosure, even of the sys tems own problems. Although it is critical to safeguard patient confidentiality, poorly designed poli cies and procedures that limit the sharing of information may be perceived by patients as a series of closed doors, locked cabinets, and private meetings. In the current system, concern about the burden of reporting and oversight, litigation, and blame has generated conflict and mistrust and cast transparency in its most negative light, resulting in resistance to disclosure of all kinds. Make all information flow freely so that anyone involved in the system, including pa tients and families, can make the most informed choices and know at any time Copyright National Academy of Sciences. This new rule is expected to supplement trust in the good training and intentions of health care professionals with trust based on good information and well-designed systems of care. Although changes in the tort system may be desirable, improving the health care system cannot wait for such change to occur. Some organizations have successfully implemented programs of increased transparency despite the liabil ity risk (Peterkin, 1990). Indeed, some evidence shows that open disclosure of errors may decrease the likelihood of malpractice loss (Kraman and Hamm, 1999; Pietro et al. The committee believes trust will improve in a health care system that poses few barriers to the flow of information, including aggregate (non-personally identifi able) research data and information about the quality of care. A health care system that operates under a rule of transparency will be more patient-centered and safer because patients will be able to recognize outdated and wrong informa tion and to share in information that affects their care, such as the results of laboratory tests, medications being taken, and the correct doses. Rule 8: Anticipation of Needs Under the current approach, health care resources are marshaled when they are needed. The system works largely in a reactive mode, awaiting complications and underinvesting in prevention. It would use predictive models to anticipate demand and allocate its resources according to those predictions, thereby smoothing workflow. The corresponding 21st century rule would state: Organize health care to predict and anticipate needs based on knowledge of patients, local conditions, and a thorough knowledge of the natural history of illness. A system that adopted this new rule would be more patient-centered and more effective. It would make and use better predictions about the flow of need and demand, allowing for anticipation of the needs of both individuals and the patient population at risk. Crises for older persons occur because anticipatory management of mul tiple problems is rare. When care hinges on scheduled office visits or emergency room visits, anticipatory management that can prevent acute hospitalization is difficult. Under the new rule, anticipation could include more and better linkages among care teams, linkages among health systems and community resources, and more frequent communication with patients through telephone consultations and Copyright National Academy of Sciences. She has recently shown signs of forgetfulness and has had two recent falls, one of which resulted in a fractured wrist. Her adult daughter and son-in-law would like her to go to a doctor and get a thorough evaluation, particularly of her forget fulness. Her fall is related to a combination of over-the-counter sleeping pills and the use of alcohol, begun during a prolonged period of grief after she became widowed. During her hospitalization, she suffers hypertension and grand mal seizures during which she aspirates; she develops severe pneumonia and spends 2 weeks intubated in an intensive care unit. At the end of this time, her broken hip finally can be repaired, but she has become so frail and confused that she cannot be transferred home and must go to a nursing home. During her time at the nursing home, her family, caregivers, and those in the hospital where she has periodic acute admissions have no guidance about the use of life-sustaining measures.

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Consider monitoring urinary arsenic excretion to assess the severity of poisoning. Note that the amount of arsine that must be absorbed to cause significant poisoning may not be large. Polyneuropathy and alteration in mental status are reported to have followed arsine poisoning after a latency of 1 to 6 months. Patients should be evaluated periodically by their physician for several months; these examinations should include hematological and urinalysis tests. Onset of hemolysis may be delayed for up to 24 hours, and acute renal failure may not become evident for as long as 72 hours after exposure. Released patients should also be instructed to rest and to drink plenty of fluids. Arsine is a colorless, flammable gas that does not burn the eyes, nose, or throat. At high concentrations it has a garlic-like or fishy smell, but a person can be exposed to a hazardous concentration of arsine and may not be able to smell it. Arsine is widely used in the manufacturing of fiberoptic equipment and computer microchips. If water or acid contacts these ores or metals, they may release arsine gas at hazardous levels. The main effect of arsine poisoning is to destroy red blood cells, causing anemia (lack of red blood cells) and kidney damage (from circulating red-blood-cell debris). Within hours after a serious exposure, the victim may develop headache, weakness, shortness of breath, and back or stomach pain with nausea and vomiting; the urine may turn a dark red, brown or greenish color. Although arsine is related to arsenic, it does not produce the usual signs and symptoms of arsenic poisoning. A doctor may give the exposed patient fluids through a vein to protect the kidneys from damage. For severe poisoning, blood transfusions and cleansing of the blood (hemodialysis) may be needed to prevent worsening kidney damage. Most people do not develop long-term effects from a single, small exposure to arsine. In rare cases, permanent kidney damage or nerve damage has developed after a severe exposure. Repeated exposures to arsine over a long period of time might cause skin or lung cancer, but this has not been studied. Specific tests can show the amount of arsenic in urine, but this information may or may not be helpful to the doctor. Standard tests of blood, urine, and other measures of health may show whether exposure has caused serious injury to the lungs, blood cells, kidneys, or nerves. Since toxic effects of arsine poisoning may be delayed, testing should be done in all cases of suspected exposure to arsine. Ask the person who gave you this form for help in locating these telephone numbers. Arsine Follow-up Instructions Keep this page and take it with you to your next appointment. Persons whose clothing or skin is contaminated with liquid ammonium hydroxide can secondarily contaminate response personnel by direct contact or through off-gassing ammonia vapor. In cases of respiratory compromise, secure airway and respiration via endotracheal intubation. Treat patients who have bronchospasm with aerosolized bronchodilators Cardiac sensitizing agents may be appropriate Consider racemic epinephrine aerosol for children who develop stridor. Aqueous solutions are referred to as significant risks of secondary contamination to aqueous ammonia, ammonia solution, and ammonium personnel outside the Hot Zone. In addition, they may be secondarily contaminated by vapor off-gassing from exposed to higher levels because of their short stature heavily soaked clothing or from the vomitus of and the higher levels of ammonia vapor found nearer to victims who have ingested ammonia.

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The intention is to strike a balance between pitching above the minimum requirements of the law and best practices as observed in Hong Kong and elsewhere. In this regard, readers can gauge what their fellow clients and contractors have done, and make their own judgment where they can strive for continuous improvements in their safety performance. In presenting the materials, the layout and contents under each topic are self-contained so that readers can have a ready reference at a glance, without too much cross-referencing. Clients Clients should put safety and health on the top of the agenda along with financial considerations. To ensure that all contracts are completed on time, on budget and safely, clients should: ensure that safety and health is not compromised ensure best value as against the lowest cost put in place safety and health considerations during the design stage have allowed sufficient time and resources for implementing the contractors safety programme. Contractors Plan emergency routes and exits, traffic routes, danger areas, loading bays, ramps, etc. Employees Follow all safety rules Ensure that all safety features and equipment installed are functioning properly Replace damaged or dull hand tools immediately Avoid horseplay or other activities that create a hazard Stop work when they are unwell or physically not fit to do the job Report any unsafe work practice and any injury or accident to the line supervisor Senior site management Inform workers of the risks present and the control measures required Evaluate risks that cannot be avoided Combat risks at source Establish emergency procedures Avoid all risks to workers Ensure that appropriate training is given Architects, structural Discuss and agree the safety and health terms engineers, and other with client designers Plan for safety and health in layout and design drawings, with due regard to buildability, future maintenance and repairs Provide information about the safety and health risk of the design after the client has decided on which contractor(s) to use Carry out periodic checks and sort out interface problems with different contractors Certify contractors claims for safety payment and conclude the final accounts. Safe Working Load Fence the site against unauthorized entry Take measures to prevent objects from falling from height and to take measures to protect members of the public (such as persons passing by the site) Provide and keep safe egress and access to the place of work, such as access to scaffolding Put up appropriate signs including traffic routes, authorized personnel only etc. Site layout Plan emergency routes and exits, traffic routes, danger areas, loading bays, ramps, etc. Temporary working desk for security Security check desk people to check safety helmets Construction Site Safety Handbook Page 23 Traffic and the first step is a suitable and sufficient risk assessment. This is likely to include drivers and other workers, and may also include visitors and the public Evaluate the risks for each hazard and the likelihood of the harm and its severity. Properly fenced workers access/egress with slip protection Construction Site Safety Handbook Page 27 Housekeeping Keep work areas free from rubbish and obstructions Maintain all floor surfaces safe, suitable and free from slip or trip hazards Ensure floor openings covered or otherwise fenced off Materials are properly stacked and stored safely Keep all passageways in good conditions: Unobstructed and clearly defined Provide adequate lighting Ensure clear sightline at breaks and corners Are lightings maintained in good working order Proper stacking of materials Construction Site Safety Handbook Page 31 Proper stacking in a temporary storage area Proper stacking of building materials Safe access Construction Site Safety Handbook Page 32 Safe access with enclosed stairway Well-protected staircase Clear and separate passageway Construction Site Safety Handbook Page 33 Clear and separate passageway Clear and separate passageway Environmentally friendly rubbish bins Construction Site Safety Handbook Page 34 Clean and rubbish free floors to prevent dust and falling objects over the floor edges Cleaner assigned to clean the floor area to keep the site environment clean Shoes cleaning bath with gravel bed Construction Site Safety Handbook Page 35 Bundled tray to prevent spillage from the container Mosquito inhibitors to maintain healthy environment Pre-planned site office with adequate lighting and covered floor surface Construction Site Safety Handbook Page 36 Regular spraying of antiseptic solutions to prevent mosquitoes and spread of disease. Portable fire extinguishers at prominent positions Fire extinguisher and sand Construction Site Safety Handbook Page 37 Fire hose reel Fire alarm bells at prominent locations Regular fire drills at the worksite Construction Site Safety Handbook Page 38 Workers being trained as fire fighter at the worksite Worker practicing the use of fire extinguisher Workers canteen used as a temporary assembly area during a fire drill Construction Site Safety Handbook Page 39 Fire warden to conduct headcount Welfare and toilet Welfare and toilet facilities need to be considered in both the pre-tender and construction phases as part of facilities the health and safety plan. Matters to be considered when planning the welfare and toilet facilities include: the work to be carried out and the health risks associated with it the duration and spread of the site locations the number of people working at different locations the distance from rest places and welfare facilities Welfare facilities also include washing facilities, changing areas, drinking water and eating facilities. Toilet facilities Fixed installation: at the site base, usually near the site office at different satellite locations, especially when the coverage of worksite is wide and far from the base Portable installation on the worksite Construction Site Safety Handbook Page 40 Washing facilities At suitable positions: hand basins or bowls water tap with buckets or receptacles shower or eye-bath where necessary. The term 5-S comes from a formal system created by the Japanese and adapted by many companies in Hong Kong. It is a set of principles and methodology of organization and standardization that goes well beyond normal housekeeping programmes, and sets Construction Site Safety Handbook Page 45 the foundation for upkeeping and improving the work environment. All parties concerned, in particular the contractors, accepted its importance and usefulness in assigning responsibilities for their operation by reminding workers of the value of exercise and preparedness of risks at the beginning of each shift in the worksite. Under this arrangement, the related subcontractors are required to assemble their employees before the start of work every day and make safety and health arrangements concerning the following matter: Providing instructions to related workers concerning the work contents, working procedures, points concerning industrial accident prevention, etc. The Project Manager will lead safety patrols, safety co-ordination meetings and after work site clean up being a normal, not exceptional, daily routine. The 5-S practice is designed to establish and maintain quality environment, and people have to be trained as the 5-S Lead Auditors to ensure implementation. The Environment, Transport and Works Bureau adopts a similar system Site Safety Cycle aiming at promoting safety and housekeeping of construction sites. Construction Site Safety Handbook Page 47 the Housing Department adopts a system called Building Pass which also encompasses similar activities in its Safety Assessment. A 5-S Charter is signed between the Society and its main contractors to ensure smooth implementation. Electricity safety Workers engaged in construction work are frequently exposed to electric currents in various forms from overhead cables, underground supply lines, to electrical installations and tools. Shocks and electrocutions can occur to workers engaged in different types of jobs. Many workers are unaware of the potential electrical hazards present in their work environment, which makes them even more vulnerable to the danger of electrocution. Others are being too ignorant to believe that electrocution is only too remote because very often they only receive minor electric shock or burns from arcing and flashover. They customarily take short-cuts by working on live apparatus without rendering the circuit dead or awaiting a permit to work in order to save time.

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This asymptomatic rise Maraviroc is the frst approved agent in this exciting in bilirubin can be used by the clinician as way to monitor new class of anti-retrovrals. Elvitegavir Fusion Inhibitors-Enfvirtide (T-20) Approved in 2012, this integrase inhibitor is only this is the frst approved agent in its class. Cobicistat is an inhibitor of cytochrome P450 allowing this agent is gven as a twice daily subcutaneous decreased metabolism of elvitegavir and hence once injection. For example, it can be gven to nursing home residents if there is an outbreak of infuenza A. Neuraminidase Inhibitors More recently a new class of agents, neuraminidase inhbitors, wth clinical activty against both infuenza A and B types have been introduced. To your intense chagrin, he then is indicated fr persons unable to tolerate oral medication begins to blow his nose loudly and drip strings of snot or critically ill persons who are not responding to oral on his plate, explaining that he has a terible fu. N Engl J Med 317: vrus, in the fmily Aenavrdae), and fr the hantavrus 185-191, 1987. Famciclovir fr the treatment of acute herpes clearance is deterined by several fctors, including the zoster: efects on acute disease and postherpetic neuralgia. Interferon is also one of several treatment options virus infction: a controlled trial in persons with fwer than fr persons with chronic hepatitis B. Efect of Alpha-Interfron Treatment in Patients with Hepatitis B e Antigen-Positive Chronic these are newer agents fr use in the battle against Hepatitis B: A Meta-Analysis. Herpes: treatment for primar (activated) primarily by viral thymi renal tubules) and recurrent genital, oral, and dine kinase (produced only in 2. Retinitis, Pneumonia, protein kinase enzyme, which is a dine kinase Esophagitis product of the Ul. Valganciclovir requires fewer pills and gains higher levels as com pared to oral ganciclovir 2. Neutropenia lated by human enzymes, it can be effective in strains with altered viral kinases 1. Alteration in serum electrolytes strains) since phosphorylation is not (calcium, phosphate) 3. Headache (60%), insomnia or mother before birh and during confusion breast feeding, and to the infant. Do not mix with ddl, due to red blood cells) increased risk of pancreatitis, hepatitis & neuropathy. The diference is that nucleotide analogues are already phosphorlated, unlike nucleoside ana logues.

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Serological survey of immunity to tetanus in adult population of Nothern Halkidiki, Greece. Studies on the relation of tetanus bacilli in the digestive tract to tetanus antitoxin in the blood. Studies on the duration of protection afforded by active immunization against tetanus. The risk of G uillain-Barre syndrome after tetanus-toxoid containing vaccines in adults and children in the United States. United Kingdom Department of Health Immunization against infectious diseases, (2006). Tetanus in developing countries: an update on the maternal and neonatal tetanus elimination initiative. R ed u ced an t igen co n t en t d ip h t h er ia t et an u s acellu lar pertussis and inactivated polio vaccine as a booster for adolescents 10 to 14 years of age. N aturally acquired tetanus immunity: further evidence in humans and animals from the Galapagos Islands. Q uantitation of anti-tetanus and anti-diphtheria antibodies by enzymoimmunoassay: methodology and applications. A n t igen ic r esp o n se t o b o o st er d o se o f d ip h t h er ia an d t et an u s toxoids. Abschliessende U ntersuchungen uber die Tetanusprophylaxe durch active Immunisierung [Final investigations on tetanus prophylaxis, through active immunization]. World H ealth O rganization, Expanded Programme on Immunization (1996a): Estimating tetanus protection of women by serosurvey. World H ealth O rganization, Expanded Programme on Immunization (1996b): the childrens vaccine initiative and the global programme for vaccines and immunization. World H ealth O rganization, Expanded Programme on Immunization (2001): Assessment of elimination of neonatal tetanus, Zimbabwe. World H ealth O rganization, Expanded Programme on Immunization (2006): Tetanus vaccine. Maternal and N eonatal Tetanus Elimination by 2005: Strategies for Achieving and Maintaining Elimination, November 2000. D ip h t h er ia an d t et an u s im m u n it y am o n g b lo o d d o n o r s in To r o n t o. Tetanus immunization: effectiveness of stimulating dose of toxoid under conditions of infection. The Departments goal is the achievement Efforts are directed towards reducing nancial of a world in which all people at risk are and technical barriers to the introduction protected against vaccine-preventable of new and established vaccines and diseases. Work towards this goal can be immunization-related technologies (Access to visualized as occurring along a continuum. The quality and safety of vaccines and other biological medicines is ensured through the development and establishment of global norms and standards (Quality Assurance and Safety of Biologicals). The following conditions were separated: Cleft lip with and without cleft palate separated to cleft lip with cleft palate; cleft lip alone (without cleft palate). In order to meet the standard level specified, a program needs to ascertain that condition. Inclusions Other names or conditions that should be included in the code for the defect. Exclusions Other names or conditions that should not be included in the code for the defect. Diagnostic Methods Postnatal procedures by which the defect may be accurately and reliably diagnosed. Prenatal Diagnoses Not Confirmed Guidance on whether cases with only a prenatal diagnosis Postnatally should be included in the defect code.

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Team practice is common, but changes in roles are often slowed or stymied by institutional, labor, and financial structures, as well as by law and custom. Some training for team practice occurs, but that training is typically fragmented and isolated by health discipline, such as medicine, nursing, or physi cal therapy. Clinicians and managers recognize the increasing complexity of health care and the opportunities presented by information technology. Some real-time deci sion support tools are available, but information technology capability is modest, and stand-alone applications are the rule. Computer-based applications for labo ratory data, ordering of medications, and records of patient encounters typically Copyright National Academy of Sciences. Crossing the Quality Chasm: A New Health System for the 21st Century 114 Copyright National Academy of Sciences. Crossing the Quality Chasm: A New Health System for the 21st Century 115 Copyright National Academy of Sciences. More organized groups rely on best practices, guidelines, and dis ease management pathways for clinicians and patients, but these are not inte grated with workflow. Stage 4 Stage 4 is the health care system of the 21st century envisioned by the committee. This system supports continued improvement in the six aims of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Health care organizations in this stage have the characteristics of other high performing organizations. They draw on the experiences of other sectors and adapt tools to the unique characteristics of the health care field. Patients have the opportunity to exercise as much or as little control over treatment decisions as they choose (as long as their preferences fall within the boundaries of evidence-based practice). Services are coordinated across prac tices, settings, and patient conditions over time using increasingly sophisticated information systems. Whatever their form, health care organizations can be characterized as learn ing organizations (Senge, 1990) that explicitly measure their performance along a variety of dimensions, including outcomes of care, and use that information to change or redesign and continually improve their work using advanced engineer ing principles. They make efficient and flexible use of the health workforce to implement change, matching and enhancing skill levels to enable less expensive professionals and patients to do progressively more sophisticated tasks (Christen sen et al. The committee does not advocate any particular organizational forms for the 21st-century health care system. What ever the organizational arrangement, it should promote innovation and quality improvement. Every organization should be held accountable to its patients, the populations it serves, and the public for its clinical and financial performance. In other cases, small systems will evolve to take on functions now per formed by larger organizations. The use of intranet or Internet-based applications and information systems may enable the development of an infrastructure to accomplish certain functions. New forms might include, for example, Web based knowledge servers or broker-mediated, consumer-directed health care pur chasing programs. They should be based on sound design principles and make use of information technologies that can integrate data for multiple uses (Kibbe and Bard, 1997a; Rosenstein, 1997). Redesigning Care Processes I try to help people understand that we can work smarter. Not only must care processes be reliable, but they must also be focused on creating a relation ship with a caregiver that meets the expectations of both the patient and the family. Redesign can transform the use of capital and human resources to achieve these ends. Redesign may well challenge existing practices, data structures, roles, and management practices, and it results in continuing change.

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When the stress and discomfort continue to build for a prolonged period of time, a person may feel emotional, mental, and physical exhaustion; that person is said to have burnout. Burnout results in reduced productivity and the person with burnout may feel helpless, hopeless, and resentful. This could happen to any health care worker who is working at a health care facility in Ebola-affected areas. Elements of Stress and Burnout Stress Burnout There is over-involvement There is disengagement Over-reactive emotions Blunting of emotions Loss of energy Loss of motivation and hopes Affects the persons physical well-being Affects the persons mental well-being How Do You Recognize if You Are Experiencing Burnout The first steps in dealing with burnout are to recognize it by being aware of its signs and symptoms, intervene to reverse burnout, and take care of your physical and mental well-being. Tips for prevention of stress and burnout: Meditate for a few minutes as you wake up and before getting out of bed. Profession counselors can help you understand your personal situation and make decisions about how you want to address your stress and burnout. However, preparedness consists of much more than a plan on paper or an intention to stockpile supplies. The four phases are: Pre-outbreak preparedness, Alert (identify, investigate, evaluate risks), Outbreak response and containment operations, and Post-outbreak evaluation. To complement this chapter, Appendix G: Checklist for Planning and Preparedness for an Ebola Virus Disease Outbreak contains a comprehensive checklist, adapted from two U. The detailed checklist captures the content of this chapter and presents it in an easy-to-use format that managers, providers, and administrators can apply or adapt to the specific situation in their facility. Ebola and Marburg Virus Disease Epidemics: Preparedness, Alert, Control, and Evaluation, Interim Version 1. Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola, at: apps. However, it is also important to develop comprehensive social mobilization campaigns that include feasible, culturally appropriate, and technically sound interventions for the population in order to control the outbreak effectively. The facility management and local health administration will need to assess the cascading consequences of response to an outbreak now: for example, school closures will affect workplaces, movement restrictions will affect provision of food and supplies, and shortages of supplies will mean setting priorities. Health care providers and administrators must work together to develop a preparedness plan for their facility, and to ensure clear communication, consensus, and commitment. Who is reporting to and coordinating with government planning bodies, local partners, practitioners, government and private health care facilities, and other institutions Things to Do Now Establish a multi-disciplinary coordination committee (or designate individuals) consisting of technical experts, program managers, administrators, and representatives of stakeholders to facilitate quick and adequate response during a crisis. All individuals should know what they are responsible for, what to do, and in what order. Make sure that job aids are disseminated and that staff members know how to use them. Consider development of alternatives for supplying the health care facility with power and drinking water; develop back up transport and telecommunications plans. The objectives of surveillance may differ according to the seriousness of the disease and the possibilities for intervention. Questions to Be Addressed What type of surveillance is considered to be necessary and feasible in the current situation and would help identify an emerging pandemic at the earliest possible stage All first-line health care workers should be trained to detect cases and identify clusters of cases. Maintain communication with designated community resource persons (community health care workers, Red Cross volunteers, religious leaders, midwives, traditional healers, village chiefs, etc. Rigorous systems are needed to identify potential outbreaks early, in order to initiate a timely response. Once an outbreak is confirmed, surveillance needs will diminish and be replaced by the need for the minimal information required to manage the outbreak. Once the brunt of the emergency is past, the need for surveillance may increase again with the need to monitor for possible re-emergence or new outbreaks.


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Please refer to Appendix H for a list of core variables for consideration, and their defnitions. However, its efect in the determination of single major congenital anomalies remains controversial. Even though some studies have shown variable degrees of association between consanguinity and non-syndromic neural tube defects, hydrocephalus and oral clefts, the majority are based on small numbers of individuals. In addition, diferences in methodological approaches hinder comparisons between the diferent studies. The data will provide the opportunity to measure the programme objectives, collect numbers of cases and help to determine trends. Once a decision is made regarding the data variables to be collected, an abstraction form (see Appendix G) can be created. Paper-based data collection For many years, data for congenital anomalies surveillance have been collected and processed using either a predetermined list (checkbox) format or the recording of verbatim descriptions on paper. These data-collection methods are still used widely for vital registration and various surveillance and research purposes. Nevertheless, well-structured, paper-based forms are often still used in low-resource settings for collecting data on congenital anomalies. Electronic data collection An alternative to paper-based data collection is electronic data collection. Gradually, data-collection methods have evolved from manual, paper-based formats to electronic formats. Improving electronic surveillance programmes can be a long and costly process that requires regular update of a systems hardware and software to maintain a high level of security and data quality. The availability of electronic data collection will depend on the resources of each country. The ideal collection tool allows data to be collected, transmitted securely to a data-management centre for storage and analysis, and retrieved, processed or analysed when necessary. In the last few decades, the evolution of technology has signifcantly improved the options for potential electronic data-collection tools. Internet advances have allowed web-based reporting to progress gradually into real-time reporting (25). The more recently introduced use of laptops, tablets and smart phones provides additional options for data collection. Because of the variability in access to, use of, and resources for electronic systems, each country will need to determine which method best fts its needs. Data collection using smart phones or tablets With the growing availability of smart phones and tablets in countries whose populations are predominantly middle and low income, their use as part of a congenital anomaly surveillance programme may improve the accuracy of data collection, and reduce the time required for, and cost of, data transmission and retrieval. Users of smart phones and tablets can capture and transmit pictures, and may have access to databases of clinical information, including photographs to assist with diferential diagnosis. Furthermore, the use of these mobile devices can be a novel, simple, efcient and instructive approach to the collection of data. The use of these technologies could ofer great potential for encouraging motivated personnel to contribute data to central databases using their mobile devices; however, such devices can easily be lost or stolen, so it is essential that they are programmed to encrypt all data, to ensure the privacy and security of information collected by the system. Data management and protocols Data management is essential to ensuring the integrity and confdentiality of surveillance data. Data management will not be possible unless all participating personnel are trained in the protocol for data collection.


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