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Greer FR avanafil 200mg on line, Sicherer SH purchase avanafil line, Burks AW buy avanafil australia. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction best 100 mg avanafil, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. The most common symptoms of food allergy in the breastfed baby are seen in the skin (eczema) and the stomach and intestines (e.g. blood in the stools) but symptoms in a baby can include: While no one knows exactly how many babies have Allergic Proctocolitis(AP), we do know that 2 or 3 children out of every 100 will have some kind of allergic reaction to milk (in exclusively breastfed infants, this number falls to 1 in 100 (1%) or less). Children with a nut allergy may also be allergic to other foods such as milk, eggs, shellfish and other types of nut. The most common food allergies in babies and young children are milk , eggs, peanuts , and tree nuts such as hazelnuts, walnuts and almonds. Many doctors recommend continuing with formula well past the first year for children who are on restricted diets due to food allergy. Milk allergy is the most common food allergy in infants and young children. If you experience seasonal allergies, your body mistakenly identifies pollen as dangerous to your health, causing an allergic reaction Your body releases antibodies and chemicals called histamines into your blood, triggering your runny nose, itchy eyes, sore throat and other unpleasant side effects. If you suffer from seasonal allergies, they probably tend to affect you the most during the spring, when trees, grasses and weeds all release pollen into the air. Hay fever is often seasonal (when pollen is in the air), but if constantly exposed to an offending substance (e.g., pet dander), symptoms can last year-round. Allergies to pollen, spores, mold, and dust (also called hay fever or allergic rhinitis) affect the respiratory system and are usually the most difficult to control. Grass pollen is the most common allergen (May to July), but tree (February to June) and weed (June to September) pollens can also cause the allergic reaction we know as hay fever. It is mainly used to relieve the symptoms of hay fever and allergic asthma to pollen, mould, house dust mite and pet allergen, as well as to control severe reactions to insect stings. The most common triggers for people with allergic rhinitis are pollen, dust mite, pet and mould allergens. An estimated 50 million people in the US suffer from seasonal allergies, or more commonly known as hay fever. Some of the most common triggers of seasonal allergies include grass, pollen and mold. Hey fever is another name for allergic rhinitis, most commonly used to describe a seasonal allergic reaction to pollen such as ragweed. The first approach in managing seasonal or perennial forms of hay fever should be to avoid the allergens that trigger symptoms. Allergic rhinitis - commonly known as hay fever - is a group of symptoms affecting the nose. Pollen allergy symptoms are commonly called hay fever.” Pollen released by trees, as well as grasses and weeds, cause these symptoms. In 2013, a study compared the efficacy of mometasone furoate nasal spray to betamethasone oral tablets for the treatment of people with seasonal allergic rhinitis and found that the two have virtually equivalent effects on nasal symptoms in people. Allergic rhinitis is typically triggered by environmental allergens such as pollen, pet hair, dust, or mold. This is known as seasonal allergic rhinitis or spring hay fever. Most people associate hay fever with spring, when airborne grass pollens are at their peak. Hay fever is the common name for a condition called allergic rhinitis, which means an allergy that affects the nose. If you have seasonal allergies, start taking your preferred medication (nasal antihistamines/steroids, oral antihistamines, or eye drops) two weeks before symptoms are likely to set in, says Clifford W. Bassett , M.D., Medical Director of Allergy and Asthma Care of New York and AAFA ambassador. According to the Asthma and Allergy Foundation of America , grasses are the most common trigger for people with hay fever. Itchy eyes, a congested nose, sneezing, wheezing and hives: these are symptoms of an allergic reaction to the environment caused when plants release pollen into the air, usually in the spring or fall. Pollen allergies, more commonly known as hay fever , are caused when trees and grasses release pollen into the air. However, the nice weather worsens symptoms in people who suffer from seasonal allergies and the accompanying runny noses and itchy,watery eyes. Hay fever is caused by an allergic response to outdoor or indoor allergens, such as pollen, dust mites, or tiny flecks of skin and saliva shed by cats, dogs, and other animals with fur or feathers (pet dander). Hay fever, also called allergic rhinitis, causes cold-like signs and symptoms, such as a runny nose, itchy eyes, congestion, sneezing and sinus pressure. American Academy of Allergy, Asthma, & Immunology: Allergic Conditions: Outdoor Allergens;" Pollen Q&A;” and Allergic Rhinitis.” "Spring is typically considered to be a tree pollen season," says James Li, MD, board-certified asthma and allergy specialist and chair of the division of allergic diseases in the department of internal medicine at the Mayo Clinic in Rochester, Minn. Pollens are the allergens that cause hay fever, one of the most common types of allergic reaction. While the symptoms of allergic rhinitis may be reduced by avoiding the triggering allergens and/or allergy medications, the only known cure of allergic rhinitis is immunotherapy. Sublingual immunotherapy is currently only FDA approved for environmental allergies but has several advantages over allergy shots, namely the ability to self-administer at home and a lower risk of side effects and allergic reactions. This collection features the best content from AFP, as identified by the AFP editors, on allergies and anaphylaxis and related issues, including allergies and asthma, allergens, allergy testing, allergic rhinitis, food allergies, and latex allergies. Immunotherapy is a type of treatment for allergic children with hay fever and/or asthma It is also called desensitization, hyposensitization, and allergy shots. Treatment options include over-the-counter and prescription antihistamines, anti-leukotrienes, nasal steroids, and nasal cromolyn Some people may have allergic asthma symptoms ( wheezing , shortness of breath , chest tightness) caused by exposure to pollen. If symptoms are not controlled by allergen avoidance, eye drops or medicine, immunotherapy (allergy shots) may be an option. Allergy shots involve injecting small amounts of allergen extracts into the body to stimulate the immune system without causing an allergic reaction. These medications block the release of immune system chemicals (histamine, leukotriene) that trigger allergic reactions of the eyes (allergic conjunctivitis ) or nasal passageway. Allergic reactions may include: sneezing, watery/itchy eyes, stuffy/runny nose, postnasal drip, head congestion, chronic cough, wheezing, asthma, headaches, skin rash, dizziness, hoarse voice, fatigue and/or recurring ear/sinus infections. Allergy shots help the body build immunity to specific allergens, thus eventually preventing or lessening reactions from exposure to the allergen. Meta-analyses have found that injections of allergens under the skin is effective in the treatment in allergic rhinitis in children 101 102 and in asthma. 6 Treatments for allergies include avoiding known allergens and the use of medications such as steroids and antihistamines 7 In severe reactions injectable adrenaline (epinephrine) is recommended. Allergy shots are a type of treatment for people with hay fever (allergic rhinitis), eye allergy (conjunctivitis), or allergic asthma, or for people with stinging insect allergy. Food allergens are defined as the specific components of food or ingredients within food recognized by allergen-specific immune cells which then elicit specific immunologic reactions, resulting in characteristic symptoms. • Eye allergies are caused by seasonal or year-long allergies and may be treated with eye drops, oral medications or allergy immunotherapy. People with seasonal hay fever (allergic rhinitis) normally notice their symptoms worsen when they go outdoors on days with high pollen counts. Although seasonal allergies are notorious for causing eye symptoms, year-round exposure to allergens can be just as problematic. Allergic Conjunctivitis: Inflammation of the tissue lining the eyelids (conjunctiva) due to a reaction from allergy-causing substances such as pollen and dander. Many people experience eye irritation caused by substances in the environment called"allergens." Pollen, dust, animal dander, and ragweed are examples of allergens. A number of allergy medications can (and do) help with the eyes: antihistamines can help to some degree, as do the daily nasal sprays. Allergic pink eye: Symptoms include itchy eyes, swollen eyelids and a runny or itchy nose. Pink eye can also be an allergic reaction to some­thing like pollen, dust mites, pets, contact lenses, or cosmetics. Also known as allergic conjunctivitis1, pink eye is a common seasonal allergy symptom. An association between wine-induced asthma and asthmatic reactions triggered by aspirin and NSAIDs was also observed, which may indicate that sensitivities to salicylates in wines play a role in the triggering of asthmatic responses in some individuals. In this study 51 asthmatic subjects (13.9%) reported sensitivity to the sulfite additives in foods, with 36 of these also reporting sensitivity to wine, representing a highly significant association (P <001). Although asthmatic responses were reported to a wide variety of alcoholic drinks, most alcohol-sensitive individuals in this study reported asthmatic responses to wines (30.3%).

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A third example described four subjects with congenital hypothyroid goiter from two unrelated families (201) order avanafil 100 mg. The former is present in the chondroitin sulfate and the complex carbohydrate units buy avanafil 200mg online, although its form and role are not known (202) buy avanafil 100mg mastercard. Of this discount avanafil 100mg with amex, about half is in the complex carbohydrate units, the remainder is present as phosphoserine and phosphotyrosine (203-205). The scheme does not account for the relative size of the intervening molecules First, iodide must be oxidized to an iodinating form. An extensive literature has sought to identify the iodinating species, but the issue is still not resolved (see (207) for a detailed review). The molecule has about 132 tyrosyl residues among its two identical chains; at most, only about 1/3 of the tyrosyls are iodinated. As isolated from the thyroid, Tg rarely contains more than 1% iodine or about 52 iodine atoms. The final step in hormone synthesis is the coupling of two neighbouring iodotyrosyl residues to form iodothyronine. Coupling takes place while both acceptor and donor iodotyrosyl are in peptide linkage within the Tg molecule. The generation of the iodothyronine residue involves the formation of an ether bond between the iodophenol part of a donor tyrosyl and the hydroxyl group of the acceptor tyrosyl (Fig 2-10). After the cleavage reaction that gives the iodophenol, the alanine side chain of the donor tyrosyl remains in the Tg polypeptide chain as dehydroalanine (215-217). Observations both in vivo and in vitro show an appreciable delay in coupling after initial formation of iodotyrosines. The scheme does not account for the relative size of the intervening molecules Fig. The free radicals could combine to generate the iodothyronine residue (at the tyrosine acceptor site) and a dehydroalanine residue (at the tyrosine donor site), which in the presence of H2O converts into a serine The distribution of hormone among several sites in the Tg molecule has been studied in a number of species (170;218-221). The second most important site is at tyrosyl 2554, which may contain for 20- 25% of total T4. A third important site is at tyrosyl 2747, which appears favored for T3 synthesis in some species. Small increments of iodine go first to tyrosyl residues 2554, 130, 685, 847, 1448, and 5, in that order. Further addition increases the degree of iodination at these sites, iodinates some new tyrosyls, and results in thyroid hormone formation at residues 5, 2554, 2747, and 685, with a trace found at 1291, in that quantitative order. These data identified the most important hormonogenic sites in hTg, and also the favored sites for early iodination. The same work recognized three consensus sequences associated with iodination and hormone formation: i) Asp/Glu-Tyr at three of the four most important sites for hormone synthesis, ii) Ser/Thr-Tyr- Ser associated with hormone formation, including the C-terminal hormonogenic site that favors T3 in some species and iii)Glu-X-Tyr favoring early iodination, although usually not hormone formation. Identifying the donor tyrosyls has attracted considerable investigational interest over the past several decades. The fact that some tyrosyls are iodinated early but do not go on to provide the acceptor ring of T4 makes them potential donor candidates (222). On the basis of in vitro iodination of an N-terminal cyanogen bromide Tg peptide, Marriq et al. A baculovirus system expressing the 1-198 fragment of Tg, either normal or mutated on tyrosyl residues, showed that iodination of a fragment containing tyrosyls only at residue 5, 107 and 130 formed T4 as did the intact normal peptide, but this fragment could also form T4 with substitutions at residue 5 or 130 (225). They proposed that Tyr130 was the donor tyrosine for the most important hormonogenic site at Tyr5. Exposure of Tg to reducing agents yields an N-terminal peptide of about 20-26kDa, depending on the animal species, that contains the major hormonogenic site of Tg (229). This peptide appears in parallel with iodination or may slightly precede it (230). Thus, iodination-associated cleavage appears to be part of the maturation of the Tg molecule. These discrete N-terminal peptides have been found in all vertebrate Tg examined so far (219). This is an iodinated albumin, shown to be serum albumin that is iodinated in the thyroid (232). In all these cases, there are abnormalities in thyroid structure which might explain the access of serum albumin to intrathyroidal iodination sites Fig. There was at first an increase in total organification, but then, as the dose was increased further, a depression of organification of iodide and an increase in the free iodide present in the thyroid gland occurred. However, in physiological conditions, serum albumin can reach thyroid follicle lumina by transcytosis i. The thyroid also iodinates lipids and many different iodolipids have been described after high doses of iodide in vitro (238;239). These findings suggested that iodination of lipids impairs H2O2 production and, therefore, decreases further Tg iodination. Water and ion extraction from the follicle lumen might represent an active process leading toTg concentration. As the follicle lumen is a site of Ca++ accumulation (244;245), the high degree of compaction of lumenal Tg might depend on electrostatic interactions between Ca++ and anionic residues of Tg, which is an acidic protein. Turnover of intrafollicular material or so-called colloid varies greatly with gland activity. For normal humans, the organic iodine pool (largely in intrafollicular material), turns over at a rate of about 1% per day (14). When the turnover increases, less Tg is stored, and with extreme hyperplasia, none is evident and the entire organic iodine content may be renewed daily (14). In this situation, secretion of Tg and resorption of Tg (see below) probably occur at similar rates and only tiny amounts of intrafollicular material are present at any time. Thyroglobulin as usually isolated from the thyroid is chiefly the 19S 660kDa dimer that has been glycosylated and iodinated. Iodination and hormone formation of Tg is more complex than generally thought because of the slow diffusion of molecules that are in a colloidal state in the follicle lumen. The diffusion coefficient of Tg which is about 26mm2 / sec in water would only be in the order of 10-100mm2 / hour in the thyroid follicle lumen. There is evidence for the presence of insoluble Tg in the form of globules of 20-120 microns, at a protein concentration of almost 600 mg/mL, in the lumen of thyroid follicles of different animal species (250). In pig, insoluble Tg contains more iodine than did the 660kDa Tg, and had virtually no thyroid hormone (252). Insoluble Tg has many internal crosslinks through disulfide bonds, dityrosine, and glutamyl-lysine bonds, the latter generated by transglutaminase (253). Depending on numerous factors including - the supply of iodide as substrate, the activity of enzymes catalyzing hormone formation, the concentration and physico-chemical state of Tg - the hormone content of lumenal Tg molecules varies to a rather large extent. Tg molecules newly arrived in the follicle lumen with no or a low hormone content would co-exist with “older” Tg exhibiting up to 6-8 hormone residues. The downstream processes responsible for the production of free thyroid hormones from these prohormonal molecules must therefore adequately manage the use of these lumenal heterogeneous Tg stores to provide appropriate amounts of hormones for peripheral utilization. One would expect to find i) control systems preventing excess hormone production that would result from the processing of excessive amounts of prohormonal Tg molecules and ii) checking systems avoiding the use of Tg molecules with no or a low hormone content. Purified porcine Tg molecules labeled by covalent coupling of fluorescein were microinjected into the lumen of a follicle. A and B, phase contrast and fluorescence images taken at the time of microinjection. C and D, fluorescence images of the top (C) and the bottom (D) of the follicle after 2hr of incubation. The way the thyroid follicle proceeds to generate free hormones from stored hormone containing Tg molecules has been known for a long time. The first step represents the limiting point in the thyroid hormone secretory pathway. Over the last decade, there has been substantial improvement in the knowledge of the cellular and molecular mechanisms governing the internalization or endocytosis and intracellular transport of the prohormone, Tg. Results obtained in rats and dogs have been for a long time extrapolated to the different animal species including human. There is now a number of experimental data indicating that in the thyroid of different species under physiological circumstances, basal internalization of Tg, mainly if not exclusively, occurs via vesicle-mediated endocytosis or micropinocytosis (reviewed in (256)), while macropinocytosis results from acute stimulation. Intralumenal Tg stores potentially subjected to endocytosis are composed of (recently secreted) non-iodinated Tg, iodinated Tg (Tg-I) and iodinated Tg containing iodothyronine residues (Tg-Ith). The internalization process starts with the organization of microdomains at the apical plasma membrane of thyrocytes; these microdomains or pits, resulting from the recruitment and assembly of proteins (clathrin, adaptins…) on the cytoplasmic side of the membrane, invaginate to finally generate coated vesicles after membrane fission.

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Toxic phase In others purchase 50 mg avanafil mastercard, afer a period of a few hours or few days where symptoms seemingly remit order avanafil discount, profound symptoms recur with high fever discount avanafil 200 mg on line, headache buy 100 mg avanafil with amex, lumbosacral pains, nausea, vomiting, abdominal pains and somnolence. The patient rapidly devel- ops jaundice and bleeding can occur from mouth, nose, eyes and/or stomach. Kidney function dete- riorates; this can range from abnormal protein levels in the urine (albuminuria) to complete renal failure with no urine production (anuria). Mode of transmission Bite of infective Aedes mosquitoes The vectors of yellow fever in forest areas in west Africa are Aedes furcifer-taylori and Aedes luteocephalus. Tere are three recognized types of transmission cycle for yellow fever and all types occur in Africa: Sylvatic yellow fever: generally results in sporadic cases most commonly among young men working in the forest; Intermediate yellow fever: results in small-scale epidemics and occurs in humid or semi-humid savannah, separate villages in an area sufer simultaneous cases; Urban yellow fever: results in large epidemics that tend to spread outwards from one source to cover a wide area. In forested areas, where the yellow fever virus circulates between mosquitoes and monkeys, the disease is continuously present throughout the year. In feld or savannah areas outside the forest areas, transovarian transmission (from one generation of mosquitoes to the next) has been documented but its contribution to the mainte- nance of infection is unknown. Period of communicability Blood of patients is infective for mosquitoes shortly before onset of fever and for the frst 3–5 days of illness. The disease is highly communicable where many sus- Communicable disease epidemiological profle 225 ceptible people and abundant vector mosquitoes coexist. Forest areas: vertebrates other than humans, mainly non-human primates, and forest mosquitoes. Epidemiology Disease burden Yellow fever is transmitted in sub-Saharan Africa and South America, but could, in principle, be seen in any Aedes aegypti-infested location. Studies indicate that morbidity and mortality attributable to yellow fever are underestimated by a fac- tor of 10–500. The precise extent of illness and death due to yellow fever is not known: cases of yellow fever go undetected because the signs and symptoms have a wide spectrum and overlap with those of many other diseases; mild cases may not seek care in a health facility; disease surveillance is not adequate to detect cases of sylvatic yellow fever that can occur in remote areas. Mandatory mass vaccinations in the 1950s kept the incidence of yellow fever low in west Africa. However, as vaccine programmes and coverage waned, yellow fever I re-emerged in the 1980s. The annual rate of infection in west Africa is about 1%, but large epidemics have occurred with high rates of attack. Between 1983 and 1999, 12 cases were reported from Côte d’Ivoire: 11 in 1997, and 1 in 1999. Since 2000, there has been a sharp rise in the number of reported cases (Table 26). In 2008, again, the Ministry of Health of Côte d’Ivoire declared an outbreak of yellow fever in Abidjan, which was laboratory-confrmed at the beginning of May. For data up to and including 2004, as well as for 2006, annual reported cases include both suspected and confrmed cases. For 2008, annual reported cases include only cases confrmed by the regional reference laboratory (Institut Pasteur, Dakar). Geographical distribution Increased circulation of the yellow fever virus in west Africa is linked to the existence of a high proportion of non-immunized subjects. The situation is aggra- vated by forced migrations of unprotected people to areas of risk and the decline of mass vaccination campaigns. Outbreaks were previously sporadic, but now are more widely distributed, with the potential for explosive urban events. Yellow fever events One confrmed case should be considered as a yellow fever event leading to an investigation and appropriate implementation of control measures. Yellow fever events, Côte d’Ivoire, 2001–2008 Date Event As of 31 July 2008 Thirteen confrmed cases since May 2008. Achieved a vaccination coverage of 100% and resulted in immunization of 26 114 persons. Also planned to vaccinate another 290 000 persons in the remainder of Buona district and the surrounding district of Boundoukou. September 2005 Outbreak in neighbouring Burkina Faso March–October 2001 A large outbreak began in the west of the country, spreading to Abidjan and in the end afecting 31 of 62 districts, with 280 cases and 22 deaths (case-fatality ratio, 8%). Ten days after the last notifcation of cases in the city, a second peak occurred in the countryside with 8 suspected cases. Risk factors for increased burden Population movement Unvaccinated people moving to areas of endemicity are at risk. Treat of epidemic transmission when a person with a forest-acquired infection travels to an A. Overcrowding Increased population density, as in urban settings, contributes to a favourable environment for the vector, Aedes aegypti. Living in temporary shelters exposes people to the increased risk of mosquito bites. Lack of safe water, poor hygienic practices and poor sanitation Poor environmental sanitation may promote vector breeding. Communicable disease epidemiological profle 229 Prevention and control measures Case management No specifc treatment for yellow fever is available. Prevention Preventive vaccination through routine childhood immunization and catch-up mass vaccination. Surveillance (case-reporting of yellow fever is universally required by the Inter- national Health Regulations, 2005). Immunization In endemic areas, immunization should be provided routinely through incorpo- ration of yellow fever vaccine in routine child immunization programmes and mass preventive campaigns. Yellow fever vaccine is included in the childhood vaccination programme in Côte d’Ivoire; vaccination coverage among the target population in 2006 was estimated at 67% according to ofcial country estimates (1). Depending on the travel patterns of infected humans or infected mosquitoes, the epidemic spreads from village to village and into cities. In sylvatic (jungle) yellow fever, nonimmunized persons should avoid tracts of jungle where infection has been localized. Morbidity, mortality and case-fatality ratio due to cholera, Côte d’Ivoire, 2001–2007. Recommendations for initiating antiretroviral therapy in adults and adolescents, in accordance with clinical stages and the availability of immunological markers. Morbidity, mortality and case fatality caused by meningococcal disease in Côte d’Ivoire, 2004–2008. Recommended treatments for human rabies according to type of contact with animal suspected to have rabies. Recommended treatment strategy for preventive chemotherapy of soil-transmitted helminthiasis. The system of health-care administration is divided into three levels: The central level includes the Minister’s Cabinet and the General and Central Departments. It is responsible for creating health-care policy and providing strategic direction at various levels of the health-care system. It is responsible for coordi- nating health-care activities at the district level. The peripheral level is represented by 79 health-care districts, which are the primary operational units. Operationally, the health-care system is also divided into three levels (Decree 96-876 of 25 November 1996): Primary level: rural health centres, urban health centres, urban health-training and community-based urban health-training centres, specialized urban health centres including school and university health centres and antituberculosis centres. Secondary level: general hospitals, regional general hospitals, specialized hos- pital centres and the Bingerville psychiatric hospital. Communicable disease epidemiological profle 244 History of the humanitarian crisis 1893 Côte d’Ivoire made into a colony of France 1960 Independence declared under President Felix Houphouet-Boigny. Later that year, Ivorian air force attacks rebels; French forces enter the fray afer nine of their soldiers are killed in an air strike. In April, President Gbagbo declares “the war is over” between his government and northern rebels, as the two sides move to dismantle the military bufer zone. Date of long-awaited presidential elections deferred from June to the end of November. Response Confrmation The lead health agency should investigate reported cases to confrm the outbreak situation – number of cases higher than that expected for the same period of year and population. Investigation Confrm diagnosis (laboratory testing of samples) Defne outbreak case defnition Count number of cases and determine size of population (to calculate attack rate) Collect/analyse descriptive data to date (e. Control Implement control measures specifc for the disease and prevent exposure I (e. If such an etiology is suspected, refer to “Acute haemorrhagic fever syndrome” for appropriate specimen-collection guidelines.

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Application of H5N1 case defnitions: The case defnitions apply to the current phase of pandemic alert (phase 3) and may change as new information about the disease or its epidemiology becomes available avanafil 50mg mastercard. The case defnitions for persons under investigation and suspected cases have been developed to help national authorities in clas- sifying and tracking cases safe 100 mg avanafil. The case defnitions are not intended to provide complete descriptions of disease in patients but rather to standardize reporting of cases cheap avanafil 50mg otc. In clinical situations purchase avanafil 100 mg amex, decisions concerning treatment, care or triage of persons who may have H5N1 infection, should be based on clinical judgment and epi- I demiological evidence, and not on adherence to case defnitions. While most patients with H5N1 infection have presented with fever and lower respiratory complaints, the clinical spectrum is broad. Mode of transmission Most human infection is reported to be afer exposure to infected birds. Human infection may occur through touching, slaughtering, plucking and butchering of infected birds and probably contact with contaminated environments. Human-to-human transmission was suspected in several clusters (cases related in time and place and documented as probable in Tailand in 2004, Indonesia in 2006, Pakistan and China in 2007). Human-to-human transmission, when sus- pected, is likely to have occurred in the context of intimate unprotected prolonged contact between a severely ill patient and the contact(s) to whom he/she trans- mitted the infection (for example, when taking care of the patient or sharing a bedroom with a patient). Incubation period Afer exposure to infected poultry, the incubation period generally appears to be 7 days or less, in many cases 2–5 days. In clusters in which limited, human-to- human transmission has probably occurred, the incubation period appears to be approximately 3–5 days. Period of communicability Limited data suggest that patients may remain infectious for as long as 3 weeks, perhaps even longer in immunosuppressed patients (i. The longest documented period has been 27 days afer the onset of illness, based upon detection of virus antigen in a patient’s respiratory specimens. Risk assessment No predisposing factors for infection have been identifed that can explain the low incidence of H5N1 observed in humans to date, despite extensive exposure. However, the risk for infection through inappropriate handling of ill birds remains. So far, no domestic mammals have been identifed as a source of infection; however, cats and dogs can become infected. Concern that additional human cases may occur in afected parts of Africa is high given the close contact between people and poultry (estimated 1. Troughout much of Africa, rapid detection and investigation of outbreaks is ham- pered by the absence of an early warning system for avian infuenza in animals or humans, inadequate diagnostic capacity, and difculties in shipping specimens, both locally and internationally, for diagnostic confrmation. Population move- ment and food insecurity increase the risk of importation from neighbouring countries to Côte d’Ivoire. Communicable disease epidemiological profle 101 Prevention and control measures Case management The patient should be isolated and strict infection-control measures applied Standard and droplet precautions should be the minimum level of precautions to be used in all health-care facilities when providing care for patients with acute febrile respiratory illness, regardless of whether infection with avian infuenza is suspected. The most critical elements of these precautions include facial protection (nose, mouth and eyes if sprays/splashes of secretions are anticipated) and hand hygiene. Terefore standard plus droplet precautions should be applied for routine care of patients with suspected or confrmed infection with avian infuenza , which comprise of adequate hand hygiene, use of gowns, clean gloves, medi- cal mask and eye protection if splashes are anticipated. Treatment with antivirals should be given in case of suspected infection (clinical presentation and notion of exposure) in the absence of an alternative diagnosis. Observational I data on treatment with oseltamivir in the early stages of the disease suggest that it is useful in reducing A(H5N1) virus infection-associated mortality. Furthermore, evidence that the A(H5N1) virus continues to replicate for a prolonged period indicates that treatment with oseltamivir is also warranted when the patient presents for clinical care at a later stage of illness. Prolonged or high-dose corticosteroids can result in serious adverse events in A(H5N1) virus-infected patients, includ- ing opportunistic infection. However, when pneumonia is present, antibiotic treatment is appropriate initially for community-acquired pneumonia according to published evidence-based guidelines. When available, the results of microbiologic studies should be used to guide antibiotic usage for suspected bacterial co-infection in patients with A(H5N1) virus infection. Monitoring of oxygen saturation should be performed whenever possible at presentation and routinely during subsequent care (e. Management of contacts Chemoprophylaxis: Antiviral chemoprophylaxis should generally be considered according to the risk stratifcation. High-risk exposure groups are currently defned as: Household or close family contacts of a strongly suspected or confrmed H5N1 patient, because of potential exposure to a common environmental or poultry source as well as exposure to the index case. Individuals with unprotected and very close direct exposure to ill or dead animals infected with the H5N1 virus or to particular birds that have been directly implicated in human cases. This group also includes laboratory personnel who might have an unprotected exposure to virus- containing samples. Communicable disease epidemiological profle 103 Low-risk exposure groups are currently defned as: Health-care workers not in close contact (distance greater than 1 metre) with a strongly suspected or confrmed H5N1 patient and having no direct contact with infectious material from that patient. Personnel involved in culling non-infected or likely non-infected animal populations as a control measure. To assist countries in prioritizing the use of antiviral drugs for chemoprophylaxis, particularly where their availability is limited, a three-tier risk categorization for exposure was developed. Where neuraminidase inhibitors are available: In high-risk exposure groups, including pregnant women, oseltamivir should be administered as chemoprophylaxis, continuing for 7–10 days afer the last exposure (strong recommendation); zanamivir could be used in the same way (strong recommendation) as an alternative. In moderate-risk exposure groups, including pregnant women, oseltamivir I might be administered as chemoprophylaxis, continuing for 7–10 days afer the last exposure (weak recommendation); zanamivir might be used in the same way (weak recommendation). Pregnant women in the low-risk group should not receive oseltamivir or zanamivir for chemo- prophylaxis (strong recommendation). Amantadine or rimantadine should not be administered as chemoprophylaxis (strong recommendation). Communicable disease epidemiological profle 104 In low-risk exposure groups, amantadine and rimantadine should not be administered for chemoprophylaxis (weak recommendation). In pregnant women, amantadine and rimantadine should not be adminis- tered for chemoprophylaxis (strong recommendation). In the elderly, people with impaired renal function and individuals receiving neuro- psychiatric medication or with neuropsychiatric or seizure disorders, amantadine should not be administered for chemoprophylaxis (strong recommendation). Health monitoring is recommended for close contacts of cases up to 7 days afer the last exposure and consists of monitoring temperature and symptoms such as cough. It is also required for health-care professionals who have had contact with patients, their body fuids and secretions, their room or with potentially contam- inated equipment. Quarantine of close contacts of suspected cases during the health-monitoring period is not necessary unless there is suspicion of human-to-human transmission. Prevention Reduce human exposure to H5N1 For individuals, the risk of bird-to-human transmission of avian infuenzas can be reduced through proper precautions; hand hygiene, hygiene precautions when handling birds (especially when ill or dead) or their products for consumption or when in environments which may be contaminated with faeces of ill birds. In communities, the risk can be reduced by control of spread of the infection in the animal population, and reduction of human contact with infected birds. Human-to-human transmission of the H5N1 can be prevented through early detection and isolation of suspected and confrmed cases in a dedicated health- care facility and application of infection-control measures. Humanitarian agencies could: Contribute to reducing human exposure to avian infuenza A(H5N1) by inform- ing communities afected by avian infuenza in birds of risks of exposure to ill or dead animals (particularly poultry/birds) and of strategies for risk avoid- ance including avoiding close contact with ill/dead animals and their remains, or to environments contaminated by their faeces, avoiding consumption of raw or undercooked poultry products, and performance of hand hygiene afer handling, slaughtering, plucking, butchering, or preparing poultry/wild birds; Communicable disease epidemiological profle 105 Ensure that the information they deliver is done in close coordination with the animal and public health authorities to prevent discrepancies in preven- tive messages. Promote immediate reporting to relevant local and national animal health authorities of unexpected illness/deaths in birds/animals. Investigate people developing unexplained acute respiratory illness afer exposure to ill/dead birds should be investigated for H5N1 infection. Agencies could support such eforts through integration of these activities into other feld programmes such as agriculture, livelihoods, food security, water and sanitation. Humanitarian agencies should facilitate the early detection, notifcation and early response to initial suspected cases and/or clusters in humans of H5N1 avian infuenza or a novel infuenza virus. It is important that relevant authorities are notifed immediately in case of any suspect die-of or severe unexplained illness in animals, especially if afecting birds. Writing Committee of the Second World Health Organization Consultation on Clinical Aspects of Human Infection with Avian Infuenza A (H5N1) Virus et al. Highly pathogenic H5N1 avian infuenza outbreaks in poultry and in humans: food safety impli- cations. Further reading Seasonal infuenza Recommendations for infuenza vaccines: Update on the recommended composition of vaccine against seasonal infuenza. Recommendations for the use of inactivated vaccines and other preventive measures. Communicable disease epidemiological profle 107 Laboratory study of H5N1 viruses in domestic ducks: main fndings. Collecting, preserving and shipping specimens for the diagnosis of avian infuenza A(H5N1) virus infection.