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By: Jennifer Lynn Garst, MD

  • Professor of Medicine
  • Member of the Duke Cancer Institute


To mitigate the health impact of these socio-economic transformations and safeguard the gains made in economic development treatment yeast uti lamotrigine 25 mg low cost, the country must prioritize the Control of chronic non-communicable diseases medications prescribed for pain are termed order 200 mg lamotrigine with amex. Development of a national cancer control plan is recommended wherever the burden of the disease is significant medicine 93 7338 buy generic lamotrigine 50mg line. To promote community involvement and participation in cancer prevention 4 medications discount 200 mg lamotrigine free shipping, control and care 2. Systematic and integrated approach to implementation of priority interventions as part of a national cancer action plan. Types of cancer control interventions vary depending on the level of cancer control continuum. This document describes in detail what kind of strategic interventions are given at various levels of care. With rapid expansion of the physical infrastructure and equipping the primary level health care (health posts, health centers and primary hospitals) throughout the country and training and deployment at health care workers the primary level health care structure and function was revitalized and health posts were made to administratively and technically link with the health centers. Leaders of the network of women influence women under their leadership to practice a healthy life style. Approximately 40% of cancers are preventable through interventions such as tobacco control, promotion of healthy diets, physical activity, vaccination and protection against exposure to environmental carcinogens. National policies and programmes should be implemented to raise awareness and reduce exposure to cancer risk factors, and to ensure that people are provided with the information and support they need to adopt healthy lifestyles. Promote physical activity in workplaces Promote healthy diet and physical activities around schools Develop and implement national guidelines on physical activity. Promote the implementation of legislation on production and consumption of alcohol. It is estimated that 20% of all cancers in developing countries and 6% in developed countries are caused by viral and bacterial infections. Prevention through vaccination, early detection and treatment of these infections will reduce the risk of these cancers. Exposure to carcinogens also occurs via the contamination of food and water by chemicals such as aflatoxins, dioxins and asbestos. Occupational carcinogens are causally related to cancer of the lung, bladder, larynx, skin, esophagus and leukemia. Regulate the disposal of toxic wastes such as industrial, nuclear and electronic wastes. Early detection and treatment of cancer is known to reduce greatly the burden of cancers such as cancer of the cervix. There is some evidence that this strategy can produce "down-staging" (increase in proportion of breast cancers detected at an early stage) of the disease to stages that are more amenable to curative treatment. There are 5 regional oncology centers under construction in five teaching hospitals located in different regions: Jimma, Hawassa, Haromaya, Mekelle and Gondar. Develop a staffing plan for optimal use of the radiotherapy unit and develop an education and in/service training plan to implement radiotherapy treatment. Develop a capacity building program for cancer registration personnel and sensitize health personnel on cancer registration. Develop a monitoring and evaluation framework for cancer Control Conduct a mid-cycle (year 2-3) assessment of plan implementation 3. In order to have better cancer Control programme, there is a dire need to strengthen the current structure and establish similar mechanisms at all levels of the health system. Produce publications and present at international and national forums to contribute to global knowledge. Health Sector Transformation Plan, Federal Ministry of Health of Ethiopia (2015/2016-2019/20) 5. Since its introduction, the screening programme has helped half the number of cervical cancer [1] cases, and is estimated to save approximately 4,500 lives per year in England. Their research examined the screening histories (mostly based on conventional cytology) of 1,305 women aged 20 to 69 years diagnosed with invasive cervical cancer, and 2,532 age-matched controls. The researchers concluded that while screening offered additional protection to all women aged from 25 to 65, implementing a uniform screening interval across all age groups was undesirable. A negative result in the previous five years confers a lower level of protection (73%). Annual screening in this age group offers only modest additional protection (88%) over three-yearly screening. Even annual screening is not as effective (76%) as three-yearly screening is for older women. All subsequent invitations to screening must be sent around 6 weeks before the woman’s test due date. The number of women screened in the previous three and five years does not correspond with the number regularly screened at intervals of three and five years, because a proportion of women will not be screened in every screening round. Data on a small random [9] sample of women is published in the national ‘Audit of invasive cervical cancers’. The International Agency for Research on Cancer also recommends that [11] women should not commence cervical screening before the age of 25. There is, however, ample evidence that screening in women aged 20 to 24 leads to the detection of large numbers of cytological abnormalities (the majority of which would resolve of their own accord) resulting in referrals to colposcopy and subsequent treatment. Evidence for screening in women aged 50 to 64: cervical screening is extremely effective in preventing cervical cancer in women aged 50 to 64. To date, no study has been able to show that cervical cancer rates in women aged 60 to 70 would not rise if screening were offered only up to age 50. Specific management algorithms have been published to manage [32] women under 25 who have symptoms of cervical cancer. The specificity and sensitivity of cervical cytology for the identification of sexually transmitted infections by cervical cytology is not high enough to permit this test to be used as a diagnostic tool. Inflammatory changes in cervical samples are not a reliable indicator of other types of genital [43,44,45] infection, and further tests must be conducted where infection is suspected. In all cases, the woman should be offered an appointment with an appropriate health professional to discuss their withdrawal. Under the Mental Capacity Act (2005), decisions can be made on behalf of such women by a legally authorised representative. A ‘best interests’ decision must be the least restrictive of all possible options and so, in most cases, it is preferable to continue with regular invitations at routine intervals, which can be accepted or declined individually. This group should be ceased from the programme, and provided with gynaecological follow-up. All cases should be considered individually, and women who are unsuitable for screening can be ceased from the programme. Between the ages of 50 and 64, women should be offered cervical screening every five years. No more than two months (62 days) should elapse between receipt of a referral from a cancer screening service to first treatment for cancer. The repeat sample should not be taken less than three months after the previous test. Women with persistent inadequate smears should undergo colposcopy to exclude invasive cancer, 4. The recommended interval for the second sample is empirical, based on the [48] experience of the sentinel sites. For information on follow-up after treatment and on the surveillance of women who have not been treated, see chapter 10. Receipt of this referral at the acute provider is the starting point for the 18-week commitment, should the woman receive a benign diagnosis. Evidence: the correlation between a cervical cytology sample showing features of invasion and the histological diagnosis of invasive cancer is high. Receipt of this referral at the acute provider is the starting point for the 18-week commitment, to which the woman should move once cancer is excluded following colposcopic examination. A referral combining cervical and extra-cervical investigations may be feasible in some cases. In these instances, colposcopic appearances may also be non-specific, but a more accurate assessment is likely to be obtained by combining cytological review, colposcopic appearances, and histological biopsy of any abnormality seen.

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Retinal detachment may occur slowly medicine vs surgery discount lamotrigine 50 mg fast delivery, weeks loss of central vision results symptoms 3 months pregnant buy cheap lamotrigine 100mg, but simple ruptures in which to medicine 20 order lamotrigine 50 mg with visa months later symptoms insulin resistance order 25 mg lamotrigine. Direct trauma at the equator can rarely the macula is not involved cause little impairment of cause tears or atrophic retinal breaks. These are treated conservatively with steroids to also be precipitated in eyes already suffering from myopia decrease infammatory changes and the extent of later cho or other peripheral retinal degenerations. Occasionally, particularly in concussion injuries associ A contusion may also cause a choroidal or supra ated with gunshot wounds, a rupture of the retina is associ choroidal haemorrhage. Such cases present a characteristic picture of traumatic proliferative chorioreti nopathy secondary to haemorrhage into the vitreous, leading Retina to traction bands. The retina may suffer oedematous or degenerative changes, Prognosis should be guarded in all cases of serious be torn, or haemorrhages may occur in it. Commotio Retinae (Berlin Oedema) Optic Nerve this is a common result of a blow on the eye. A milky white cloudiness due to oedema appears over a considerable area the optic nerve may be injured in fractures of the base of at the posterior pole which may sometimes disappear after the skull by fragments of the optic canal. Avulsion although vision may be good at frst, central vision gradu of the optic nerve is very rare in civilian life but occurs in ally diminishes, the loss of function being associated gunshot wounds of the orbit. Haemorrhages of the optic with the development of pigmentary deposits at the macula. Intraocular Pressure this may be seriously disturbed following concussion inju ries, particularly if they are severe. Angle recession is associated with traumatic effects on the outfow channels leading to an insidious glaucoma. Ghost cell obstruction of the trabeculae in long-standing vitreous haemorrhages may also induce a secondary glaucoma. Such glaucoma may be controlled by medication, but is sometimes intractable even to operative treatment. The patient should immediately have an eye to cause chorioretinal adhesions and prevent future retinal shield applied and be thoroughly examined under general detachments. Evaluation for repair should be done at the same Occasionally in a corneal wound caused by a dirty im time. The gravity of such injuries is due to the immediate plement or vegetable matter, pyogenic organisms are carried damage to the eye, post-traumatic iridocyclitis (a common into the eye, multiply there and cause rapid necrosis of sequel to a perforating wound), the introduction of infection the entire cornea. In these cases a ring of deep infltration and sympathetic ophthalmitis, one of the most dreaded com appears 2 or 3 mm internal to and concentric with the plications of perforating wounds. If the organism is Pseudomonas aeruginosa (an anaerobic Gram negative rod), there is extensive chemosis of the conjunctiva, Wounds of the Conjunctiva sometimes with a greenish discharge. Enzymes released Wounds of the conjunctiva are common and should be by the organism cause liquefaction of the cornea. The institution of intensive treatment with appropriate local and systemic antibiotics and a thera Wounds of the Cornea and Sclera peutic keratoplasty may occasionally save such eyes. The margins swell up If it fnds access into the anterior chamber, pyogenic soon after the accident and become cloudy due to accumu infection leads to a purulent iridocyclitis with hypopyon, lation of fuid, thus facilitating closure of the wound and endophthalmitis and usually panophthalmitis. If small and limited to the centre, corneal wounds heal well unless they become Wounds of the Lens infected, in which case treatment is like that of a perforating ulcer (Fig. Such wounds cause traumatic cataract and are always a If the wound is large, an adhesion of the iris or its serious complication. In small recent injuries, the entry of aqueous causes a localized cloudiness in its the prolapsed iris should be replaced with the help of intra vicinity and, irrespective of the site of the wound, opacities ocular miochol or pilocarpine and the wound repaired with in the form of feathery lines appear in the posterior cortex, 10-0 nylon sutures. If the iris appears non-viable, it must which later develop into a rosette-shaped cataract resem be abscised and the edges of the wound sutured directly re bling that of early concussion cataract (Fig. Occa placing fxed anatomical landmarks such as the limbus into sionally the wound in the capsule becomes sealed, particu continuity frst and then suturing anteriorly and posteriorly as larly if a posterior synechia develops, in which case these required. However, they usually progress limbus are sutured completely after a thorough exploration. The integrity of the They are also treated with surrounding cryoapplications posterior lens capsule must be assessed pre-operatively so that appropriate surgery is planned. If the lens is damaged, it rapidly opacifes and focculent grey masses protrude through the opening in the capsule, sometimes flling the whole chamber. A traumatic cataract of this type is liable to lead to serious complications if not aspirated at once. The swelling of the lens keeps the iris in contact with the cornea and a secondary glaucoma may ensue. The treatment of traumatic cataract in association with penetrating wounds, especially if complicated by vitreous loss, is by the use of a vitrectomy instrument. The aim of surgery is to remove the cataract, perform an adequate vitrectomy, suture the globe as a primary procedure, and insert an intraocular lens in suitable cases. Adequate steps are essential to ensure control of infec tion and infammation by intraocular and topical antibiotics and steroids. They excite a virulent panophthalmitis with Mechanical Effects a brownish discharge and gas bubbles in the anterior cham ber. Although they are sensitive to penicillin, destruction of the foreign body may enter the eye through either the vision has always followed. Having penetrated the cornea, it may be if this infection is introduced into the eye, the localized retained in the anterior chamber where it may fall to the cephalic type of tetanus often results. Whenever such a bottom and, if very small, lie deeply in the angle hidden complication is suspected, as in agricultural or road acci by the scleral ledge where it can only be seen gonioscopi dents, if the patient is not already immunized, prophylactic cally (Fig. A piece of Risk factors for poor visual return include a double glass in the anterior chamber is exceptionally diffcult to penetrating or perforating injury, dense vitreous haemor see because its refractive index differs so little from that of rhage and blunt trauma as a causative factor. The foreign body may pass into or through the lens, either by way of the iris or the pupil (Fig. The foreign bodies most great diagnostic signifcance, since it rarely occurs, except likely to penetrate and be retained in the eye are minute as the result of perforation by a foreign body. The foreign chips of iron or steel (accounting for 90% of the foreign body may be visible in the lens, either before or after dilata bodies in industry), stone, and particles of glass, lead tion of the pupil, but it is possible for it to pass through the pellets, copper percussion caps and, less frequently, spic iris and through the circumlental space without wounding ules of wood. If cornea, iris and lens; through the cornea, pupil and lens; the foreign body is large, severe damage is usually caused. If it comes to rest in the vitreous it may remain sclera and lodge in the deeper parts of the eye. By the introduction of infection, and scopically in the vitreous or retina, and the track through 3. By specific action (chemical or otherwise) on the intra the vitreous often appears as a grey line. Chapter | 24 Injuries to the Eye 395 Reaction of the Ocular Tissues to a Foreign Body this varies with the chemical nature of the foreign body. Non-organic Materials these materials can (i) be inert, (ii) excite a local irritative response that leads to the formation of fbrous tissue, often resulting in encapsulation, (iii) produce a suppurative reac tion or (iv) cause specifc degenerative effects. Although inert materials cause little or no reaction at the time, irido cyclitis may eventually develop. Stone may occasionally give rise to chemical changes, depending on its composition. Lead, usually occurring as shot-gun pel entry is seen as a leucomatous corneal opacity overlying a sphincter tear. Aluminium frequently becomes powdered and excites a local reaction; so does zinc, which may excite suppuration—a reaction often associated with nickel and retina where it may ricochet once or even twice before it constantly with mercury. Occasionally it pierces the coats of the eye common materials found, undergo electrolytic dissociation and comes to rest in the orbital tissues, a condition known and are widely deposited throughout the eye causing impor as a double perforation of the eye. If it lies in the retina, the foreign body, generally black and often with a metallic lustre, is surrounded by a white Iron exudate and red blood-clot, but eventually it is usually this causes siderosis, so does steel in proportion to its encapsulated by fbrous tissue and the retina in the neigh ferrous content. The condition is probably due to the electrolytic disso Apart from its chemical nature, the lodgement of a ciation of the metal by the intrinsic resting current in the foreign body in the posterior segment frequently leads eye, which disseminates the metal throughout the tissues to degenerative changes, which may damage sight consid and enables it to combine with the cellular proteins, thus erably. These may entail a widespread degeneration, but damaging especially the epithelial cells and causing atro most frequently fne pigmentary disturbances at the mac phy. The vitreous usually turns fuid, bands of of iron in the anterior capsular cells of the lens, where fbrous tissue may traverse it along the path of the foreign oval patches of the rusty deposit are arranged in a ring body, haemorrhage may be extensive and retinal detach corresponding with the edge of the dilated pupil. The iris is also characteristically stained, frst greenish and later reddish-brown. Deposition of iron in the As with other perforating wounds, the introduction of sphincter of the iris leads to a mydriasis. The vision of these infection is an ever-present danger when a foreign body eyes, however little affected by the primary injury, gradu enters the eye.

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This is an alternative to symptoms of lamotrigine 25mg visa what is now the standard in the developed world medicine - purchase 200mg lamotrigine overnight delivery, the common mistakes are: the Lichtenstein repair medications versed purchase 50 mg lamotrigine visa, where a mesh is sewn in to acute treatment best 200 mg lamotrigine (1). The other ‘definitive’ operation, an abdominal pain or vomiting, especially if the hernia lies the Shouldice repair, is difficult to do correctly and is not under an apron of fat. To repair a hernia, especially a direct one, before dealing with the cough, asthma, constipation or poor urinary flow that have provoked it. If you are experienced, and no suprapubic catheter has been used, you may be able to carry out a prostatectomy and hernia repair at the same operation. Not to transfix the neck of the sac high enough, so as to obliterate it completely; a simple ligature on its own may slip off. You will have many inguinal hernias to repair, so let them provide you with an unhurried opportunity to increase your anatomical knowledge and your surgical skills. As you’ll find you spend much time operating on hernias, it is worth teaching an assistant to learn this procedure. The hernial sac is closely related to the spermatic Their repair (herniorrhaphy) is usually simpler, unless they cord, and lies in the same fascial planes. A special variety of direct hernia in which the patient has a narrow defect in the conjoint tendon, or in the transversalis fascia (18-10). This is a Busoga (or Gill-Ogilvie) funicular type of hernia; it is not uncommon in certain areas (hence the name, Busoga, in Uganda) and may predominantly affect women. Recurrence is a problem with any inguinal hernia, especially if the patient is old and has weak muscles. Preventing recurrence needs care and skill, but curing a hernia that has recurred needs even more skill. Recurrence is less likely if you: (1) Repair a hernia early, before it has grown too large. If you leave the neck or fail to define the sac all round, a hernia is much more likely to recur. A few direct inguinal hernias bulge through a weakness in (7) Use non-absorbable sutures. They do not (8) Deal with asthma, a cough, urinary flow difficulties, present through the internal ring, they lack any special or constipation before the repair. Because of the is usually related to haemorrhage, and both will weaken way they arise, the spermatic cord lies behind an indirect your repair. The external (superficial) inguinal ring is an opening in the Women less often have indirect hernias, and seldom have external oblique aponeurosis just above and lateral to the pubic spine. An indirect hernia presents a bulge in the this aponeurosis forms the anterior wall of the inguinal canal: groin, sometimes with a dragging feeling. As the spermatic cord passes down the inguinal canal, the muscle and tendon of the into the scrotum. The patient may say that he felt internal oblique and transversus arch over it, to form the conjoint tendon. Often the hernia has been Divide the inguinal canal into thirds: in the lateral ⅓, the internal oblique present since childhood (congenital). An operation, forms its lateral wall; in the central ⅓ it forms its roof; in the medial ⅓ (as part of the conjoint tendon), it forms its floor. A hernia deforms this which will remove the risk of strangulation, and possibly normal anatomy, but you can always see that this was its original state. The inferior epigastric vessels leave the femoral artery and vein, and run longitudinally on the medial side of the internal inguinal ring. Direct hernias bulge medial to them, through the posterior wall of the inguinal canal, while indirect ones pass lateral to them through the this is expensive and difficult to get; it is unlikely to be internal ring. The inguinal ligament is attached to the antero-superior iliac understood that the hernia must be completely reduced spine laterally, and to the pubic tubercle medially. At its medial end a before application, and it is likely to be very small curved ligament, called the lacunar ligament, joins it to the pubic uncomfortable in a hot climate. A few of its fibres continue laterally along the upper border of the keeping the hernia orifice closed. Ordinary direct hernias, which seldom strangulate In an infant, the 2 inguinal rings overlie one another; in the adult they separate, although not always in some people. They may cause no symptoms, and remain the you will meet two very constant vessels, but you can easily control same size for long periods, and so may not need surgery. A, coverings of the spermatic cord, which also become the coverings of an inguinal hernia. The abdominal wall muscles are: B, external oblique; the linea semilunaris is the curved lateral tendinous edge of the rectus abdominis. If, with your finger and thumb squeezing Ask the patient to stand, cough or strain to make the bulge on the spermatic cord, you can get above the swelling, appear. Testicular atrophy is one of the complications of herniorrhaphy, Suggesting a femoral hernia (18. Take note of previous scars to see if it to the femoral vessels, whereas the inguinal hernia is is a recurrent hernia. If there is a history of a inguinal swelling that comes Suggesting inguinal lymphadenopathy: the swelling is and goes, make a determined effort to demonstrate the constant, and below the inguinal ligament. Suggesting filariasis: a thickened oedematous spermatic Review the situation later, and wait until you have actually cord, with no cough impulse (34. Suggesting a varicocoele: a soft swelling feeling like a ‘bag of worms’ in the spermatic cord, which fills from below, unlike the hernia which fills from above. Do not confuse them with inguinal passing through the internal and external rings, and lying antero hernias. A, enormous swellings of similar sizes in an superiorly to the vessels of the cord. It will show up the tissue planes as the result of progressive lymphatic obstruction. Look for microfilariae or Do not use it in children, or if the patient is tense and schistosoma eggs in skin snips. For small hernias it can be a disease or malignancy, the risks may outweigh the little shorter, and for large ones a little longer (18-7A). Find and tie securely or diathermy the superficial epigastric and superficial external pudendal vessels. In a teenager, or young adult with a small indirect If they bleed later, a postoperative haematoma results. If it does produce pain, all you need do is excise Apply straight haemostats to all bleeding points, the sac and narrow the internal ring as it is usually a and secure haemostasis. If it is large, repair the defect superficial fascia down to the shining fibres of the external with a darn. For bilateral hernias, discuss whether the patient wants both operated at the same time; recovery will be slower Clear the upper skin flap from the underlying aponeurosis and the risk of urinary retention greater. Persuade a smoker to stop; if the operation external ring, and identify the line of the inguinal canal. Make a short split incision in the aponeurosis of the If you are unsure of the anatomy, mark a line from the external oblique in the length of its fibres over the inguinal antero-superior iliac spine and the pubic tubercle with a canal, and extend it with a half-closed blade of scissors marking pen: this is the line of the inguinal ligament. Clip the upper and lower borders of the external oblique aponeurosis with straight haemostats. If you do this, you will not mistake them later for the curved haemostats you have used to control bleeding. Lift each flap of aponeurosis and use gauze or sharp dissection to free it as far as the inguinal ligament inferiorly, which is the lower border of this aponeurosis. You will now see the internal oblique muscle, leading medially to the conjoint tendon. Look for the ilio-hypogastric nerve, and, a little below it, for the ilio-inguinal nerve on the surface of the cremaster, Fig. Try not to crush or overstretch either of these nerves, or include them in a suture, because this may cause persistent postoperative pain. Pick up the cord where it crosses the pubic tubercle and gently free it posteriorly, dissect it out enough to put a sling or rubber catheter round it (kinder than the forceps shown in the figure, 18-7F), and retract it. With your left thumb in front and index finger behind, try to stretch the cord and identify the sac. This might be readily visible, but usually needs you to split the fascial layers of the cord to see the curved white edge of the sac. You will see this lying close to and in front of the spermatic cord, which contains the vas and the spermatic vessels. Do not try blunt dissection near the ring where landmarks are hard to distinguish, especially if there is much extraperitoneal fat.

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This could explain the absence of many previously identified virus species that are no longer found despite Uncontrolled urbanization has many adverse human health con continued surveillance (Vasconcelos et al 606 treatment syphilis generic lamotrigine 50 mg visa. Probable Factors in Emergence of Arbovirus Gold Mining and Malaria in Venezuela in Brazilian Amazon Region and Association with Human Disease (Vasconcelos et al medicine bobblehead fallout 4 lamotrigine 25mg low cost. It is presently affected by defores Virus Probable Factors for Emergence in Humans tation mainly associated with logging medicine and manicures generic 100mg lamotrigine with visa, agriculture the treatment 2014 200 mg lamotrigine mastercard, dam construction, and gold mining. Before 1980, malaria was occasionally reported from Dengue poor mosquito control; increased yes, epidemic urbanization in tropics this state among the indigenous population. Malaria in this area was classified by Gabaldon (1983) as difficult to control since the vector, Guaroa flooding of dama yes, sporadic An. Also, the human populations were mainly Gamboa flooding of dama; migrating birds not yet Amerindians with seminomadic habits in remote areas (Gabaldon 1983). Mayaro deforestation yes, limited During the late 1950s, construction was started on a road to con outbreak nect Ciudad Bolıvar,´ capital of Bolivar state, to Boa Vista, capital of Oropouche deforestation; increase of colonization yes, epidemic Roraima state in Brazil. The road construction brought workers from all and urbanization in Amazon over the country and opened new opportunities for people seeking land Triniti flooding of dama not yet for agriculture, gold and diamond mining, and forest exploitation. In the 1980s, the boom of gold and diamonds attracted a wave of migrants Yellow fever urbanization in tropics; deforestation; yes, epidemic from different parts of the country as well as illegal migrants from lack of widespread immunization Brazil, Guyana, Colombia, and Dominican Republic, among others. Anopheles A flooding of dama not yet Malaria started to increase steadily, reaching the highest peak of over virusesb 30,000 cases in 1988, with over 60% cases due to P. Malaria has since become endemic-epidemic in Bolıvar´ c viruses use of subsoil state. Studies carried out in several villages spanning 1999–2000 showed a During construction of dam in Tucurui, Pará State, millions of that only three species of anophelines were caught on human landing hematophagous insects were obtained in a few days, from which several catches: An. In general, biting densities were low (fewer that two bites b In this serogroup of family Bunyaviridae, the new viruses Arumateua, per person per hour). Nevertheless, there was a strong correlation Caraipé, and Tucurui were isolated, and there was also an increase in between An. The most productive breeding sites in terms of anophelines spe for several purposes) from phlebotominae sandflies. This section focuses on in In terms of morbidity and mortality, dengue fever—caused by a fectious diseases linked to urbanization. It is caused by a flavivirus and is endemic in about 100 countries and found in 14. Around 80 Lymphatic filariasis is one of the most prevalent tropical diseases, million cases are reported every year, of which 550,000 people with some 120 million people infected, primarily in India and need hospital treatment and about 20,000 die. Although dengue Africa, where there has been no decline in the incidence of the is primarily a tropical disease, it has become a great concern in disease for the past decade. In Southeast Asia, urban Bancroftian filari aegypti, a day-biting mosquito that prefers to feed on humans and asis Wuchereria bancrofti infection, a filarial nematode, is related to that breeds at sites typically found in the urban environment: dis poor urban sanitation, which leads to intense breeding of C. This species has made extraordinary evolutionary environment, but rapidly invaded as soon as forest clearing began adjustments to coexist with human beings since its origins in Af and settlement expanded (Asmerasinghe in press). In urban East rica as a forest species feeding principally on wild animals (rodents Africa, filariasis is also transmitted by C. The transmission of malaria in urban areas in the Americas occurs the spread of the disease is associated with the geographical when urbanization invades the habitat of vectors. These phenomena expansion of the vector species, favored by current housing and have been observed in cities of Brazil such as Belem´ (Para´ state) water supply conditions as well as garbage collection practices in located near the mouth of the Amazon River and in Manaus (Ama developing countries. The anopheline species diversity has in level, in residential urban areas and the incidence of dengue infec creased from 2 in the 1930s to 6 in the 1940s to 10 in the 1990s. Moreover, communi approximately 20 years, probably due to the destruction of breeding ties with high infestations of Ae. During this period forests that maintain yellow fever virus, face a significant risk of the reported malaria cases were attributed to human immigration from yellow fever epidemics. In the population of Belem´ increased from 206,331 in 1942–43 to creased aridity and eventual desertification due to increasing 934,322 in 1980–89 and then to 1,367,677 in 1996. Coc malaria cases went from 363 in 1942–43 to 1,197 in 1980–89 and cidioidomycosis is spread by dust, and disease outbreaks are often 2,716 in 1996. Approximately 80% of the original forest has been de preceded by increased rain, followed by dry periods, and espe stroyed (Povoa et al. A well-documented out the District of Daent) toward the forested protected area and low break followed the 1994 Northridge, California, earthquake, coastal swampy areas provided new larval habitats, resulting in a when 317 cases resulted (Schneider et al. In a study in higher mosquito diversity and closer proximity between human dwell Greece, factors thought to contribute to the extraordinary in ings and mosquito habitat, which increases the transmission of malaria. Nevertheless, the accelerated expansion of the suburbs into 1994) the surrounding jungle reestablished the contact between the human Leishmaniasis has been associated with urban settlements in population and the principal vector, An. There adapting to new circumstances; for example, mosquitoes have varied are two major types of leishmaniasis: cutaneous and visceral (kala their feeding time in areas where humans have intervened (Tadei et al. At present, malaria cases continue to be reported from the adapt to urban settings with some vegetation and cycling in dogs. Uncontrolled urbanization or colonization near forest areas has been typically associated with the emergence of Oropouche fever and Mayaro fever viruses (Vasconcelos et al. Coastal waters in both industrial and developing relationship between malaria and urbanization in two cities is pre countries are frequently contaminated with untreated sewage (see sented in Box 14. In tropical areas, cases are reported spond rapidly to changes in environmental conditions and are year-round. In temperate areas, cases are mainly reported in the therefore sensitive biological indicators of the combined influ warmest season. The seventh cholera pandemic is currently ences of climate change and soil and water pollution. In 1992, a new blooms are associated with several environmental factors, includ strain or serogroup (V. During the 1997/98 El Nino,˜ and runoff (which affects nutrient levels), as described in Chapters excessive flooding caused cholera epidemics in Djibouti, Somalia, 12 and 19. Some species of copepod zooplankton apparently occurs through consumption of shellfish or brackish water or provide an additional marine reservoir for V. Interannual variability in virus emerged in Malaysia in 1999, causing over 100 human cholera incidence in Bangladesh is also linked to El Nino/South-˜ deaths (Chua et al. This highly pathogenic virus (with a ern Oscillation and regional temperature anomalies (Lobitz et al. The ecological changes that caused this virus to invade a new niche appear to be a complex series of anthropogenic alterations 14. First, the virus appears not to be able to move between tropical forest communities, with their high levels of directly from bats to humans, so the development of a pig industry biodiversity, and agricultural communities, with their relatively in Malaysia has been a crucial driver of emergence. Second, fruit homogenous genetic makeup but high population densities of hu bat habitat has been largely replaced in peninsular Malaysia by mans, domestic animals, and crops. A number of species are endemic to remote oceanic genic to humans; 61% of these are zoonotic and 75% of those considered islands, and these may harbor enzootic and potentially zoonotic patho as emerging pathogens are zoonotic (Taylor et al. Because threats to wildlife habitat are so Thus it is essentially a zoonosis (Hahn et al. This is essentially a process of natural selection in which agents in Argentina, Bolivia, and Venezuela, transmitted to humans anthropogenic environmental changes perturb the host-parasite dynamic through the urine of wild rodents, came through the expansion of agricul equilibrium, driving the expansion of those strains suited to the new envi tural practices to new areas; hantaviruses, initially recognized in Korea, ronmental conditions and driving expansion of others into new host spe came through the urine of infected rodents and were then identified in cies (Cunningham et al. The Junin virus, which causes a hemorrhagic fever, also immense pool of varied pathogen strains circulating within the population emerged when the production of vegetables that serve as food source for (c. The influenza virus is an example, which causes examples, it is possible that the new strains were already present in the pandemics in humans after periodic exchange of genes between the vi pathogen population. For example, recent work shows that drug-resistant ruses of wild and domestic birds, pigs, and humans. Also, in West Africa, a large share of protein in the the appearance of Pteropus vampyrus (the key Nipah virus reser diet comes from bushmeat; in Cote d’Ivoire, for example, 83,000ˆ voir) for the first time at the index farms, where Nipah virus was tons are eaten each year (Feer 1993) and in Liberia, 75% of meat initially identified (Chua et al. In order to transfer between humans and non-human primates is not a trivial improve the protein content in the diet of cattle, ground-up risk. This practice was claimed as economi opportunity for cross-species transmission and the emergence of cally rational because it turned a waste product into a valuable novel microbes into the human population. But from an ecological perspective it was anything but ra linked to the expansion of bushmeat consumption that may have tional; cattle are normally vegetarian, and are certainly not canni played a key role in the early emergence of human immunodefi bals (Prusiner 1997).

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