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Different biopsy techniques (aspiration biopsy, needle biopsy, incisional biopsy, excisional biopsy) should be learned and be performed by well trained surgeons. Cytopathologic and histopathologic examination requires professional expertise with a strong background in oncopathology. In many instances, especially with early diagnosis programmes in place, sur gery that encompasses a suffcient margin of normal tissue is suffcient therapy. Thus surgi cal skills and facilities for such surgery should be available at the district level. Although some other cancers, such as oesophagus, lung, liver, and stomach, may be cured by surgery alone, the numbers of early stage patients are very small, and their treatment may make large demands on skills and resources. The objective of surgery for residual disease post chemotherapy or radio therapy is to provide local cancer control and better chances for adjuvant therapy. The major beneft of such surgery is related to the availability of adjuvant therapy. Cytoreduction (surgery for debulking) is critical in certain solid tumors, such as ovarian cancer. Except in rare palliative care settings, there is no role for reductive surgery in patients in whom little other effective therapy is pos sible. Surgery is rarely indicated for metastatic patients (for example, with solitary metastases to lung, liver or brain). In oncology emergencies, surgery can relieve bowel obstruction, promote cessation of bleeding, close perforations, relieve compression and provide drainage of ascites or pleural effusions. Surgical techniques for reconstruction and rehabilitation can improve function and cosmetic appearance, thus helping to improve quality of life and sometimes restoring patients to occupational activities. Palliative neurosurgical procedures can provide pain relief and relieve functional abnormalities, and thus improve the quality of life of some patients. Role of radiotherapy Radiotherapy ranks with surgery as the most important methods of curing local cancer. Radical radiotherapy can effect cures in head and neck cancers, 72 73 Diagnosis and cancer of the cervix, prostate and early Hodgkin disease, and a number of Diagnosis and Treatment of unresectable brain tumours of young people. Treatment of Cancer Radiotherapy is often administered before surgery (preoperative, neoad Cancer juvant), after debulking surgery with gross residual tumour, or after surgery without clear excision margins (adjuvant) when this surgery is undertaken to preserve function. Radiotherapy either facilitates surgery or consolidates surgical gains, and reduces local recurrence following anal and rectal carci nomas, brain tumours, and breast-conserving surgery for breast cancer. Palliative radiotherapy is of value in life-threatening situations, such as profuse bleeding from a tumour or the superior vena cava syndrome. Radiation also provides effective palliation in cases of pain secondary to bone metastasis, tumours causing bleeding or compressive syndromes, such as spinal cord compression or cerebral metastatic disease. Radiotherapy is a capital-intensive specialty, requiring high technol ogy equipment and skilled technicians, found only in tertiary centres. Nevertheless, the costs per patient treated are low if the equipment is used optimally, as most of the costs are initial capital expenditure with relatively low running costs or consumables. Thus savings on personnel, that reduce machine use, increase the costs per patient treated to a level far beyond the savings realized. For both techniques, quality assurance is essential, with demands on imaging and medical physics services. A single dose fraction, or a small number of fractions, will often have an appreciable palliative effect and obliviate the need for protracted therapy schedules. Accelerators are more expensive and require sophisticated maintenance and frequent calibration. In the absence of a service contract, breakdowns of major components may incur signifcant emergency funding. The higher dose rates that accelerators can provide will reduce treatment times, and they will also permit more exact limitation of the felds, but improved imag ing, planning and immobilization are required to realize these advantages. A further advantage is the availability of electrons, which are used in about 15% of all radiotherapy patients in advanced radiotherapy departments, espe 72 73 Diagnosis and cially for the treatment of neck nodes, sparing dose to the spinal cord and Diagnosis and Treatment of skin tumours.


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Cyanosis resulting from pulmonary edema may be strikingly improved by oxygen administration, whereas cyanosis occurring with structural cardiovascular anomalies may show little change with this maneuver. Squatting Squatting is a relatively speci c symptom, occurring almost exclusively in patients with tetralogy of Fallot. It has virtually disappeared except in countries where chil dren with tetralogy of Fallot do not have access to surgery. When experiencing a hypercyanotic or "tet" spell, cyanotic infants assume a knee/chest position, whereas older children squat in order to rest. In this position, the systemic arterial resistance rises, the right-to-left shunt decreases, and the patient becomes less desaturated. Neurologic symptoms Neurologic symptoms may occur in children with cardiac disease, particularly those with cyanosis, but are seldom the presenting symptoms. Stroke may be seen in cyanotic patients and the rare acyanotic child with "paradoxical" embolus occurring via an atrial septal defect. Stroke may also occur intra or postoperatively, or as a result of circulatory support devices, and in cardiomyopathy, and rarely in children with arrhythmia. Prenatal history A prenatal history may also suggest an etiology of the cardiac malformation if it yields information such as maternal rubella, drug ingestion, other teratogens, or a family history of cardiac malformation. In these instances, a fetal echocardio gram is often performed to identify possible anomalies of the heart or other organ systems. Other facts obtained on the history that may be diagnostically signi cant will be discussed in relation to speci c cardiac anomalies. In some patients, these ndings equal the diagnostic value of the cardiovascular ndings. Cardiac abnormalities are often an integral part of generalized diseases and syn dromes: recognition of the syndrome can often provide a clinician with either an answer or a clue to the nature of the associated cardiac disease. Vital signs Blood pressure In all patients suspected of cardiac disease, examiners should record accurately the blood pressure in both arms and one leg. Doing this aids in diagnosis of conditions causing aortic obstruction, such as coarctation of the aorta, recognition of condi tions with "aortic runoff," such as patent ductus arteriosus, and identi cation of reduced cardiac output. The patient should be in a quiet, resting state, and the extremity in which blood pressure is being recorded should be at the same level as the heart. A properly sized blood pressure cuff must be used because an undersized cuff causes false elevation of the blood pressure reading. In infants, placing the cuff around the forearm and leg rather than around the arm and thigh is easier. Although a 1-inch-wide cuff is available, it should never be used because it leads uniformly to a falsely elevated pressure reading except in the tiniest premature infants. Failure to pause between readings does not allow adequate time for return of venous blood trapped during the in ation and may falsely elevate the next reading. Maximum Arm Age Range Width (cm) Length (cm) Circumference (cm)a Newborn 4 8 10 Infant 6 12 15 Child 9 18 22 S m alladu lt Adult 13 30 34 Large adult 16 38 44 Th igh aCalculated so that the largest arm would still allow bladder to encircle arm by at least 80%. Adapted fromNational HighBloodPressure Education Program Working Group onHighBlood Pressure in Children and Adolescents. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. For manual methods, the cuff should be applied snugly and the manometer pressure quickly elevated. A blood pressure cuff is placed on an extremity, and the hand or foot is tightly squeezed. As the cuff is slowly de ated, the value at which the blanched hand or foot ushes re ects the mean arterial pressure. By connecting two blood pressure cuffs to a single manometer and placing one cuff on the arm and the other cuff on the leg, simultaneous blood pressure can be obtained.

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Con ellos, no solo reduciremos la posibilidad de crecimiento fungico y proliferacion sino que tambien mantendremos la integridad fisica de los granos en lo que respecta al ataque de insectos. Estos no solo atacan el grano y lo deterioran sino que tambien son vectores transportadores que actuan como diseminadores de la microfora y contribuyen a la contaminacion fungica. El propio metabolismo del insecto eleva el contenido de humedad o agua libre del sustrato y la rotura que provocan del pericarpio permite la infeccion del interior del grano. Los tegumentos intactos del grano difcultan el acceso del hongo al almidon endospermico. Micotoxinas y Micotoxicosis en Animales y Humanos 87 No hay que olvidar que los pajaros contribuyen signifcativamente para el deterioro del grano y por lo tanto se debe evitar al maximo que esto ocurra utilizando sistemas adecuados para ahuyentarlos, como son los clasicos espantapajaros. Es evidente que el control, exigencia y rugosidad en la calidad de las materias primas en el momento de la compra y uso de estas sin contaminacion detectable para la elaboracion tanto de los alimentos compuestos para animales como de los alimentos para humanos, es uno de los primeros pasos ha tener en consideracion en la eliminacion o reduccion de las micotoxicosis. Sin embargo otros factores como son la higiene constante y la desinfeccion periodica en el almacenamiento de materias primas y en las plantas de fabricacion donde son elaborados los generos alimenticios, asi como el analisis para control del producto acabado, deben ser tenidos tambien en cuenta y puestos en practica a fn de continuar con los objetivos de prevencion de riesgos anteriormente referidos. Es aconsejable la conservacion de materias primas con niveles de humedad, maximo de 9% para algunas oleaginosas como el girasol integral y maximo de 12% para las amilaceas y la soja integral, que darian en general, actividades de agua (aw) igual o inferiores a 0,65. Con esto evitariamos en gran manera el crecimiento y proliferacion fungica y la posible produccion de micotoxinas en las materias primas almacenadas. Se recomienda a ser posible mantener una temperatura relativamente baja en el interior de los silos de almacenamiento. El uso de sistemas de introduccion forzada de aire seco y frio en estos silos, ayuda extraordinariamente a evitar las zonas de microfora y ha reducir pues la humedad y la temperatura de la masa alimentar. En general los hongos crecen y proliferan bien a una temperatura superior a 20 C y una actividad de agua (aw) superior a 0,70, que corresponderia aproximadamente a una humedad o agua libre en el sustrato superior a 13,5% para amilaceas, de 12,5 y 9,5% para oleaginosas como la soja integral y el girasol integral, respectivamente. La produccion de micotoxinas se puede efectuar a una temperatura superior a 20 C y con actividades de agua (aw) a partir de 0,85, que corresponderia aproximadamente a una humedad o agua libre en el sustrato superior a 17% para amilaceas, de 16 y 11,5% para oleaginosas como la soja integral y el girasol integral, respectivamente. Con actividades de agua inferiores a 0,85, la produccion de micotoxinas es en general, nula o muy baja. Con respecto a la temperatura, destacamos que la zearalenona es producida, en general, a temperaturas de 10-12 C. El crecimiento de bacterias se efectua a partir de actividades de agua (aw) de 0,90. Los estudios efectuados con algunos de ellos estan aun en la fase de planta piloto o laboratorial. Otros son impracticables, o bien por su elevado costo, o por la falta de sufciente efectividad en la detoxifcacion o bien porque mismo siendo economicos y efectivos, estos dejan residuos en el alimento que despues por otro lado pueden ser perjudiciales a la salud. En general, estos metodos deben ser sistemas que esten preparados para el tratamiento de grandes cantidades de alimento. Su aplicacion debe ser capaz de conseguir la descontaminacion, detoxifcacion o inactivacion de concentraciones elevadas de micotoxina. En estos metodos se debe tener en cuenta que a veces la micotoxina puede estar protegida dentro del alimento por estar unida a estructuras proteicas o bien a otros constituyentes. Estos metodos deben tener en cuenta en su forma de aplicacion, que la micotoxina, debido a las zonas de microfora, no esta uniformemente repartida en la masa alimentar, estos deben ser efcaces, baratos y no deben modifcar signifcativamente los valores nutritivos del alimento, el tratamiento no debe dejar residuos que despues puedan ser adversos para la salud animal y humana. Citaremos de una forma breve los metodos que pueden ser aplicables para fnes de prevencion, descontaminacion, detoxifcacion e inactivacion mas o menos con una signifcativa efectividad. Algunos de ellos son comunes tanto para la elaboracion de alimentos compuestos para animales como para la elaboracion de los alimentos para humanos. El problema se origina cuando esas materias primas ya vienen contaminadas con micotoxinas antes del almacenamiento. Los metodos de seleccion de granos de cereales y los descascados y posterior separacion mecanica de la cascara y el polvo, del resto del cereal, resultan ser adecuados para una descontaminacion visto que habitualmente la mayor concentracion de micotoxinas ocurre en el pericarpio de los granos y en el polvo de cereal. Sistemas tales que pueden ser utilizados tanto en los alimentos para animales como para humanos. Micotoxinas y Micotoxicosis en Animales y Humanos 89 Los tratamientos termicos tambien pueden dar buenos resultados en lo que a la fora fungica se refere. En la fabricacion de alimentos compuestos y alimentos para humanos, la granulacion a temperaturas de 70-80 C y los procesos de extrusion y expandido son excelentes en esencial para conseguir una signifcativa reduccion o eliminacion de la fora fungica, sin embargo, las micotoxinas son en general bastante resistentes a ciertas temperaturas, asi pues, las afatoxinas, ocratoxina A y fumonisinas resisten temperaturas hasta 120, 100 y 150 C, respectivamente. La patulina resiste muy bien los procesos de pasteurizacion y temperaturas de 100 C. La vomitoxina o deoxinivalenol es resistente a temperaturas de 150 C y mas, incluso las utilizadas en la elaboracion del pan, galletas y otros productos del trigo y la toxina T-2, diacetoxiscirpenol y zearalenona, resisten temperaturas de 120, 120 y 110 C, respectivamente.

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Disease incidence paradoxically may increase as improvement in living conditions delays infection to older ages, when symptoms are likely to be more severe. Catch-up vaccination for this age group may be warranted elsewhere in the context of ongoing outbreaks among children. Immunocompromised patients may have prolonged shedding of virus, along with severe and persistent gastrointestinal illness. Data are currently lacking as to whether screening programs reduce population prevalence of chlamydial genital infection. Because diagnostic methods are imperfect, treatment should not await defnitive diagnosis. It is likely a cause of pelvic infammatory disease but appears to cause milder disease than N. Quinolones, especially moxifoxacin, are active against all of the genital mycoplasmas. Dermacentor variabilis, Dermacentor andersoni, and Rhipicephalus sanguineus ticks transmit the infection in the eastern two thirds, western, and southwestern United States, respectively. Other manifestations include head ache, myalgias, nausea, vomiting, and abdominal pain. Tere are many other less common manifestations, such as meningitis, encephalitis, and osteomyelitis. A fourfold rise in immunoglobulin G (IgG) titer from acute illness to convalescence confrms the diagnosis. Vascular injury ofen leads to hypoproteinemia, hypoalbuminemia, and electrolyte abnor malities. A fourfold rise in IgG titer from acute illness to convalescence confrms the diagnosis. Polymerase chain reaction assay of swab or tissue of eschar pretreatment is very sensitive. All members of the Anaplasmataceae are obli gately intracellular bacteria that survive within vacuoles of host cells generally derived from the bone marrow, but also occasionally endothelial cells. Evolutionary models of the emergence of methicillin-resistant Staphylococcus aureus. Vancomycin is the drug with which there is the most clinical experience in coagulase-negative staphylococcal infections, although case reports support use of daptomycin and linezolid. More than 150 diferent strains have been identifed based on diferent M-protein types. It is a group A streptococcus based on its carbohydrate structure, according to Lancefeld typing of hemolytic strains. Mucoid strains are rich in hyaluronic acid capsule, and numerous extra cellular toxins are produced by most strains, which include streptolysin O, a cholesterol specifc cytolysin, streptolysin S, a cell-associated hemolysin, fbrinogen-binding proteins, streptokinase, numerous pyrogenic exotoxins that act as superantigens, and a cysteine protease called pyrogenic exotoxin B. Cultures of impetiginous lesions will distinguish Streptococcus from Staphylococcus aureus as the cause. Classic signs of necrotizing infections are not apparent until late in the course at a time that the patient has systemic shock and organ failure. Intensive care support, aggressive fuid resuscitation, ventilator support, and surgical intervention are commonly required. Nonsuppurative Poststreptococcal 131 Sequelae: Rheumatic Fever and Glomerulonephritis Stanford T. The specifc antigen(s) involved in this immune-complex nephritis is still somewhat unclear. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. The efcacy of the 23-valent polysaccharide vaccine against adult pneumonia is less clear. For immunocompromised adults, vaccination with the 13-valent conjugate, followed greater than or equal to 8 weeks later with the 23-valent polysaccharide vaccine, is recommended. Widespread pneumococcal vaccination of children has reduced the overall incidence of invasive disease and hospitalization for pneumonia in all age groups in the United States.

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Arachnoiditis, vasculitis, or diffuse cere bral edema (cysticercal encephalitis) is treated with corticosteroid therapy until cerebral edema is controlled and albendazole or praziquantel therapy is completed. Calcifcation of cysts may require prolonged or indefnite use of anti convulsants. Intraventricular cysticerci often can be removed by endoscopic surgery, which is the treatment of choice. Careful attention to hand hygiene and appropriate disposal of fecal material is important. Examination of stool specimens obtained from food handlers who recently have emigrated from countries with endemic infection for detection of eggs and proglottids is advisable. Other Tapeworm Infections (Including Hydatid Disease) Most infections are asymptomatic, but nausea, abdominal pain, and diarrhea have been observed in people who are heavily infected. More problematic is autoinfection, which tends to perpetuate infection in the host, because eggs can hatch within the intestine and reinitiate the cycle, leading to development of new worms and a large worm burden. Praziquantel and nitazoxanide are not approved for this indication, but dosing guidelines are avail able for children 4 years of age and older (praziquantel) and 1 year of age and older (nitazoxanide) for other indications. Diagnosis is made by fnding the characteristic eggs or motile proglottids in stool. Praziquantel is not approved for this indication, but dosing is provided for children 4 years of age and older for other indications. In the United States, small foci of endemic transmission have been reported in Arizona, California, New Mexico, and Utah, and a strain adapted to wolves, moose, and caribou occurs in Alaska and Canada. Dogs, coyotes, wolves, dingoes, and jackals can become infected by swallowing protoscolices of the parasite within hydatid cysts in the organs of sheep or other intermediate hosts. Dogs pass embryonated eggs in their stools, and sheep become infected by swallowing the eggs. These cysts usually grow slowly (1 cm in diameter per year) and eventually can contain several liters of fuid. If a cyst ruptures, anaphylaxis and multiple secondary cysts from seeding of protoscolices can result. Cystic lesions can be demonstrated by radiography, ultrasonography, or computed tomog raphy of various organs. Echinococcus multilocularis, a species for which the life cycle involves foxes, dogs, and rodents, causes the alveolar form of hydatid disease, which is characterized by invasive growth of the larvae in the liver with occasional metastatic spread. The alveolar form of hydatid disease is limited to the northern hemisphere and usually is diagnosed in people 50 years of age or older. In nonresectable cases, continuous treatment with albendazole has been associated with clinical improvement. Infection with D caninum is prevented by keeping dogs and cats free of feas and worms. Control measures for prevention of E granulosus and E multilocularis include educating the public about hand hygiene and avoiding exposure to dog feces. Generalized tetanus (lockjaw) is a neurologic disease manifesting as trismus and severe muscular spasms, including risus sardonicus. Cephalic tetanus is a dysfunction of cranial nerves associated with infected wounds on the head and neck. This organism is a wound contaminant that causes neither tissue destruction nor an infam matory response. The action of tetanus toxin on the brain and sympathetic nervous system is less well documented. C tetani also produces tetanolysin, a toxin with hemolytic and cytolytic properties; however, its effect on clinical presentation of tetanus has not been elucidated. Organisms multiply in wounds, recog nized or unrecognized, and elaborate toxins in the presence of anaerobic conditions. Contaminated wounds, especially wounds with devitalized tissue and deep-puncture trauma, are at greatest risk. Widespread active immunization against tetanus has modifed the epidemiology of disease in the United States, where 40 or fewer cases have been reported annually since 1999. The incubation period ranges from 3 to 21 days, with most cases occurring within 8 days. A protective serum antitoxin con centration should not be used to exclude the diagnosis of tetanus.

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Because it is uncertain if tetanus toxin can be absorbed through mucous membranes, the hazards associated with aerosols and droplets remain unclear. Special Issues Vaccines the vaccination status of workers should be considered in a risk assessment for workers with this organism and/or toxin. While the risk of laboratory-associated tetanus is low, the administration of an adult diphtheria tetanus toxoid at 10-year intervals further reduces the risk to laboratory and animal care personnel of toxin exposures and wound contamination, and is therefore highly recommended. Corynebacterium diphtheriae Corynebacterium diphtheriae is a pleomorphic gram-positive rod that is isolated from the nasopharynx and skin of humans. The organism is easily grown in the laboratory on media containing 5% sheep blood. Natural Modes of Infection the agent may be present in exudates or secretions of the nose, throat (tonsil), pharynx, larynx, wounds, in blood, and on the skin. Travel to endemic areas or close contact with persons who have returned recently from such areas, increases risk. Naturally occurring diphtheria is characterized by the development of grayish white membranous lesions involving the tonsils, pharynx, larynx, or nasal mucosa. An effective vaccine has been developed for diphtheria and this disease has become a rarity in countries with vaccination programs. Francisella tularensis Francisella tularensis is a small gram-negative coccobacillus that is carried in numerous animal species, especially rabbits, and is the causal agent of tularemia (Rabbit fever, Deer fy fever, Ohara disease, or Francis disease) in humans. Type A and Type B strains are highly infectious, requiring only 10-50 organisms to cause disease. The incubation period varies with the virulence of the strain, dose and route of introduction but ranges from 1-4 days with most cases exhibiting symptoms in 3-5 days. Occasional cases were linked to work with naturally or experimentally infected animals or their ectoparasites. Natural Modes of Infection Tick bites, handling or ingesting infectious animal tissues or fuids, ingestion of contaminated water or food and inhalation of infective aerosols are the primary transmission modes in nature. Occasionally, infections have occurred from bites or scratches by carnivores with contaminated mouthparts or claws. Direct contact of skin or mucous membranes with infectious materials, accidental parenteral inoculation, ingestion, and exposure to aerosols and infectious droplets has resulted in infection. Infection has been more commonly associated with cultures than with clinical materials and infected animals. Laboratory personnel should be informed of the possibility of tularemia as a differential diagnosis when samples are submitted for diagnostic tests. Helicobacter species Helicobacters are spiral or curved gram-negative rods isolated from gastrointestinal and hepatobiliary tracts of mammals and birds. There are currently 20 recognized species, including at least nine isolated from humans. Since its discovery in 1982, Helicobacter pylori has received increasing attention as an agent of gastritis. Natural Modes of Infection Chronic gastritis and duodenal ulcers are associated with H. Transmission, while incompletely understood, is thought to be by the fecal-oral or oral-oral route. Legionella pneumophila and other Legionella-like Agents Legionella are small, faintly staining gram-negative bacteria. They are obligately aerobic, slow-growing, nonfermentative organisms that have a unique requirement for L-cysteine and iron salts for in vitro growth. There are currently 48 known Legionella species, 20 of which have been associated with human disease. Natural Modes of Infection Legionella is commonly found in environmental sources, typically in man-made warm water systems. The mode of transmission from these reservoirs is aerosolization, aspiration or direct inoculation into the airway.

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In these species the virus causes vesicular lesions on the tongue and lips, and sometimes of the skin. Asymptomatic B virus shedding accounts for most transmission among monkeys and human workers, but those working in the laboratory with potentially infected cells or tissues from macaques are also at risk. Exposure of mucous membranes or through skin 206 Biosafety in Microbiological and Biomedical Laboratories breaks provides this agent access to a new host, whether the virus is being shed from a macaque or human, or present in or on contaminated cells, tissues, or surfaces. When working with macaques directly, virus can be transmitted through bites, scratches, or splashes only when the animal is shedding virus from mucosal sites. Zoonotically infected humans should be cautioned about autoinoculation of other susceptible sites when shedding virus during acute infection. All macaques regardless of their origin should be considered potentially infected. These prevention tools were not implemented in each of the fve B virus fatalities during the past two decades. Guidelines are available for safely working with macaques and should be consulted. To minimize the potential for mucous membrane exposure, some form of barrier is required to prevent droplet splashes to eyes, mouth, and nasal passages. Specifcations of protective equipment must be balanced with the work to be performed so that the barriers selected do not increase work place risk by obscuring vision and contributing to increased risk of bites, needle sticks, scratches, or splashes. Agent Summary Statements: Viral Agents 207 Special Issues Post-exposure prophylaxis with oral acyclovir or valacyclovir should be considered for signifcant exposures to B virus. Therapy with intravenous acyclovir and/or ganciclovir in documented B virus infections is also important in reduction of morbidity following B virus zoonotic infection. Because of the seriousness of B virus infection, experienced medical and laboratory personnel should be consulted to develop individual case management. Human Herpes Virus the herpesviruses are ubiquitous human pathogens and are commonly present in a variety of clinical materials submitted for virus isolation. In approximately 10% of infections, overt illness marked by fever and malaise occurs. It is also associated with the pathogenesis of several lymphomas and nasopharyngeal cancer. Children surviving infection may evidence mental retardation, microencephaly, motor disabilities and chronic liver disease. Herpesvirus simiae (B-virus, Monkey B virus) is discussed separately in another agent summary statement in this section. Occupational Infections Few of the human herpesviruses have been documented as sources of laboratory acquired infections. Healthcare workers in contact with risk group patients were infected more frequently than healthcare workers without contact with risk groups. Workers without contact with risk group patients were infected no more frequently than the control group. Natural Modes of Infection Given the wide array of viruses included in this family, the natural modes of infection vary greatly, as does the pathogenesis of the various viruses. Latency is a trait common to most herpesviruses, although the site and duration vary greatly. Clinical specimens containing the more virulent Herpesvirus simiae (B-virus) may be inadvertently submitted for diagnosis of suspected herpes simplex infection. All human herpesviruses pose an increased risk to persons who are immunocompromised. Containment recommendations for herpesvirus simiae (B-virus, Monkey B virus) are described in the preceding agent summary statement. Special Issues Vaccine A live, attenuated vaccine for varicella zoster is licensed and available in the United States. In the event of a laboratory exposure to a non-immune individual, varicella vaccine is likely to prevent or at least modify disease. The most common clinical manifestations are fever, headache, malaise, sore throat and cough. The two most important features of infuenza are the epidemic nature of illness and the mortality that arises from pulmonary complications of the disease. Infuenza A is further classifed into subtypes by the surface glycoproteins that possess either hemagglutinin (H) or neuraminidase (N) activity.

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Following these instructions can prolong the life of the housing to the stoma for purpose of cleaning and maintenance and enables a and reduce the likelihood of an air leak through the seal. It is possible to allow for greater taken out quickly it can become clogged with mucus. It also makes it easier for health care value the ability to speak in a more natural way and the freedom of providers to recognize the laryngectomees unique anatomy in case using both hands. Some learn that it is possible to keep the seal much emergency respiratory ventilation is needed. If this condition is not longer when they use a voice amplifer thus requiring less efort and rapidly recognized ventilation may be administered through the mouth generating less air pressure. If the seal survivors in the community, their identity is hidden from outward lasts, one can keep it overnight. They also do not want to expose anything that is disfguring without glue, even enabling one to speak. It is also possible to use the and want to be inconspicuous and appear as normal as possible. Some individuals feel that being a laryngectomee is only a small part of who they are as a person; they do not want to "advertise" it. Tere are advantages and repercussions to each approach and the fnal selection is up to the individual. It enables the individual to exhale pulmonary air from the trachea into the esophagus through a silicone prosthesis that connects the two; the vibrations are generated by the lower pharynx. The indwelling prosthesis generally lasts a longer time than the patient managed device. However, prosthesis eventually leak mostly because yeast and other microorganisms grow into the silicone leading to incomplete closure of the valve fap. When the valve fap does not close tight anymore, fuids can pass through the voice prosthesis (see below in Causes of voice prosthesis leak section, page 75). The patient managed voice prosthesis allows a greater degree of If the prosthesis leaks or has become dislodged or has been removed independence. It can be changed by the laryngectomee on a regular accidentally, a patient-changed prosthesis can be inserted by those basis, (every one to two weeks). Leakage of the prosthesis from the center (lumen) can A number of factors determine an individuals ability to use a be temporarily handled by inserting a plug (specifc to the type and patient managed prosthesis: width of the prosthesis) until it can be changed. Leakage through the voice prosthesis is predominantly due to An indwelling voice prosthesis does not need to be replaced as situations in which the valve can no longer close tightly. Inevitably, all prostheses nel page will fail by leaking through, whether from Candida colonization or. Another diference is that the insertion strap should not The trade-of is that having such a voice prosthesis may require more be removed from the patient-changeable prosthesis because it helps to efort when speaking. It may Generally a larger diameter voice prosthesis is heavier than a smaller occur when the puncture that houses the prosthesis widens. During one, and the weakened tissue is ofen not able to support a bigger insertion of the voice prosthesis, some dilation of the puncture takes device, making the problem even worse. However, some believe that place, but if the tissue is healthy and elastic, it should shrink back using a larger diameter prosthesis reduces the speaking pressure (larger afer a short time. The inability to contract may be associated with diameter allows better airfow) which allows greater tissue healing to gastroesophageal refux, poor nutrition, alcoholism, hypothyroidism, occur while the underlying cause (most ofen refux) is treated. Whenever this occurs, the voice prosthesis Both types of leakage can cause excessive, strenuous, coughing moves back and forth in the tract (pistoning), thereby dilating the tract. The leaked fuid can enter the lungs and causing aspiration length should be inserted. If the tissue around the prosthesis does not heal around the prosthesis while drinking colored liquid. If leakage occurs and the shaf within this time period, comprehensive medical evaluation is cannot be corrected afer brushing and fushing the voice prosthesis, it warranted to determine the cause of the problem. Another cause of leakage around the prosthesis is the presence With the passage of time, a voice prosthesis generally tends to of narrowing (stricture) of the esophagus.

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Centers for Disease Control and Prevention defines public health surveillance as the ongoing, systematic collection, analysis, interpretation, and timely dissemination of health data essential for public health action, program planning and implementation, the monitoring of health trends and disparities, and for the evaluation of public health practices. The information is aimed at guiding the structuring of policy recommendations and ongoing surveillance activities, rather than for research. Oral diseases may jeopardize a childs physical growth, self-esteem and capacity to socialize. A national report designed to monitor improvements in health status cited multiple unmet goals, especially in childrens oral health, and substantiated the continued high prevalence of oral diseases in children. Dietary changes may increase risk for tooth decay and receding gums expose new tooth surfaces that may be susceptible to caries (tooth decay). Periodontal disease risk, infections affecting supporting tissues of teeth, increase with age especially among tobacco 1 users and individuals with diabetes. It is estimated that these congenital birth defects occur in about 1 of every 1,000 live births. Alaska has a system to monitor these conditions, provide early intervention, and arrange for needed services. Oral and pharyngeal cancers are the fourth most frequently diagnosed cancer among black males and seventh most frequently diagnosed cancer among white males. The risk factors for oral cancer are tobacco use, excessive alcohol consumption, and exposure to sunlight. Beyond this information, the only oral health information available in the 1990s was from periodic dental assessments by the Indian Health Service (1991 & 1999) and specific studies. Information on oral clefts later became available with the Division of Public Health implementation of the Alaska Birth Defects Registry. The program also outlined future opportunities to include oral health questions and dental assessments as part of other department surveillance rd activities. The Alaska Dental Action Coalition has discussed entering into a dialog with the Alaska State Hospital and Nursing Home Association to get information on dental-related emergency-room visits. The program is continuing to assess the feasibility of expanding oral health surveillance activities as opportunities arise. By 2012, expand the oral health component of the existing surveillance system to provide more comprehensive and timely data. By 2012, enhance the surveillance system to assess the oral health needs in special populations. By 2012, develop a system to assess the distribution of the dental workforce and the characteristics of dental practitioners. By 2012, encourage stakeholders to participate in surveillance activities and make use of the data that are obtained. By 2014, implement a surveillance system to monitor dental caries in one to four-year-old children. Data Needs Several data sources are used to monitor oral diseases, risk factors, access to programs, utilization of dental services and the dental health workforce in Alaska. Data are needed to identify problems, set priorities and assess progress towards goals and objectives. As part of the State Oral Health Plan development, a workgroup assessed data needs and current capacity. The following table provides information about data sources, whether data are available at state or regional levels, and the data collection time frame. Note that oral health indicators are not necessarily collected during each year the data source is available. By collecting data in a consistent manner, communities and states can compare their data with data collected by other organizations or agencies. In the observed oral health survey, gross dental or oral lesions are recorded by dentists, dental hygienists, or other appropriate health care workers in accordance with state law. For all age groups the examiner records presence of untreated cavities and urgency of need for treatment. School-age children are also examined for presence of sealants on permanent molars. Sampling Frame/Population Under Surveillance A stratified random sampling of Alaska elementary schools is used to select a rd representative sample of kindergarten and/or 3 grade children using the regions utilized in the departments Behavioral Risk factor Surveillance System.

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Metronidazole (500 mg, twice daily for 7 days; or 250 mg, orally, 3 times a day for 7 days) is the preferred treatment during pregnancy. Current data suggest that oral treatment regimens are preferred, although intravaginal clindamycin may be an option but only during the frst half of pregnancy. Species from the gastrointestinal tract are recovered in patients with peritonitis, intra-abdominal abscess, pelvic infammatory dis ease, postoperative wound infection, or vulvovaginal and perianal infections. These species cause infection as opportunists, usually after an alteration of the bodys physical barrier and in conjunction with other endogenous species. Endogenous infection results from aspiration, spillage from the bowel, or damage to mucosal surfaces from trauma, surgery, or chemotherapy. Because infections usually are polymicrobial, aerobic cultures also should be obtained. Use of an anaerobic transport tube or a sealed syringe is recommended for collection of clinical specimens. Rapid diagnostic tests, including polymerase chain reaction and fuorescent in situ hybridization, are available in research laboratories. Bacteroides infections of the mouth and respiratory tract generally are susceptible to penicillin G, ampicillin, and extended-spectrum penicillins, such as ticar cillin or piperacillin. Some species of Bacteroides and almost 50% of Prevotella species produce beta-lactamase. More than 80% of isolates are susceptible to cefoxi tin, ceftizoxime, linezolid, imipenem, and meropenem. Acute symptom atic infection is characterized by rapid onset of nausea, vomiting, abdominal discomfort or pain, and bloody or watery mucoid diarrhea. Infammation of the gastrointestinal tract and local lymphatic vessels can result in bowel dilation, ulceration, and secondary bacte rial invasion. Colitis produced by Balantidium coli often is indistinguishable from colitis produced by Entamoeba histolytica. Fulminant disease can occur in malnourished or other wise debilitated or immunocompromised patients. Cysts excreted in feces can be transmitted directly from hand to mouth or indirectly through fecally contaminated water or food. B procyonis also is a rare cause of extraneural disease in older children and adults. Ocular larva migrans can result in diffuse unilateral subacute neuroretinitis; direct visualization of worms in the retina sometimes is possible. Reports of infections in dogs raise concern regarding potential for the infection to be moved into closer contact with people. Embryonated eggs containing infective larvae are ingested from the soil by raccoons, rodents, and birds. The eggs are 60 to 80 m in size and have an outer shell that permits long-term viability in soil. In ocular disease, ophthalmo logic examination can reveal characteristic chorioretinal lesions or rarely larvae. Preventive therapy with albendazole should be considered for children with a history of ingestion of soil potentially contaminated with raccoon feces; however, no defnitive preventive dosing regimen has been established. Polymerase chain reaction fngerprinting suggests that some B hominis organisms are disease associated but others are not. The presence of 5 or more organisms per high-power (400 magnifcation) feld can indicate heavy infection with many organisms, which, to some experts suggests causation when other enteropathogens are absent. Some experts recommend that treatment should be reserved for patients who have persistent symptoms and in whom no other pathogen or process is found to explain the gastrointestinal tract symp toms; randomized controlled treatment trials for both nitazoxanide and metronidazole have demonstrated beneft in symptomatic patients. Trimethoprim-sulfamethoxazole and iodoquinol have been used with limited success (see Drugs for Parasitic Infections, p 848). Other experts believe that B hominis does not cause symptomatic disease and recommend only a careful search for other causes of symptoms. The most common clinical manifestation of blastomycosis in children is pulmonary disease, with fever, chest pain and nonspecifc symptoms, such as fatigue and myalgia.


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