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By: V. Kafa, M.A., M.D.

Professor, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine

Global Health Security: Closing the Gaps in Responding to Infectious Disease Emergencies muscle relaxant whiplash generic nimodipine 30 mg with mastercard. Macfarlane2 muscle relaxant tablets cheap 30mg nimodipine overnight delivery, Charlanne Burke3* muscle relaxant medication over the counter generic nimodipine 30mg visa, Kumnuan Ungchusak4 and Suwit Wibulpolprasert5 Former Associate Director for Health muscle relaxant drugs flexeril purchase 30mg nimodipine overnight delivery, Rockefeller Foundation Southeast Asia and Africa Regional Offices, United States; 2Department of Epidemiology and Biostatistics, School of Medicine, University of California San Francisco, United States; 3Rockefeller Foundation, United States; 4Department of Diseases Control, Ministry of Public Health, Thailand; 5Office of Permanent Secretary, Ministry of Public Health, Thailand 1 We examine the emergence, development, and value of regional infectious disease surveillance networks that neighboring countries worldwide are organizing to control cross-border outbreaks at their source. The regional perspective represented in the paper is intended to serve as an instructive framework for others who decide to launch such networks as new technologies and emerging threats bring countries even closer together. Sometimes referred to as sub-regional, these ``self-organizing' networks complement national and local government recognition with informal relationships across borders among epidemiologists, scientists, ministry officials, health workers, border officers, and community members. Their development over time reflects both incremental learning and growing connections among network actors; and changing disease patterns, with infectious disease threats shifting over time from local to regional to global levels. Not only has this regional disease surveillance network model expanded across the globe, it has also expanded from a mostly practitioner-based network model to one that covers training, capacity-building, and multidisciplinary research. We explore how regional disease surveillance networks add value to global disease detection and response by complementing other systems and efforts, by harnessing their power to achieve other goals such as health and human security, and by helping countries adapt to complex challenges via multi-sectoral solutions. We note that governmental commitment and trust among participating individuals are critical to the success of regional infectious disease surveillance networks. Here, we tell the story of surveillance networks that neighboring countries worldwide are organizing to control outbreaks at their source, across national borders. Sometimes referred to as sub-regional, these ``self-organizing' disease surveillance networks complement national and local government recognition with trust-based relationships between practitioners across borders. The regional perspective represented in the paper is intended to serve as an instructive framework for others who decide to launch or join existing regional networks as new technologies and emerging threats bring countries even closer together. Anticipating and supporting the development of a health desk within the re-emerging East African Community, countries familiar with working together wanted to prepare common procedures for combating disease threats such as Ebola or, more commonly, cholera (11). The Rise of Self-Organizing Regional Disease Surveillance Networks Regional networks have increased in response to changing global disease dynamics. Common drivers include increased cross-border trade, mobility and migration of humans and animals, livestock productions systems, population density, viral adaptation and ecological shifts as a result of climate change (8). While some of the more recently emerging regional disease surveillance networks are research-focused, the earlier networks were practitioner-based and aimed to bring together epidemiologists responsible for surveillance. These phases reflect both incremental learning and growing connections among network actors and changing disease patterns, with infectious disease threats shifting over time from local to regional to global levels. Phase 1: Training and connecting people to contain local epidemics (1996 to 2007) During the early phases of network formation, populations struggled with diseases of primarily local concern. As the first step in establishing these networks, their members made and formalized connections among technical experts across the ministries of health and other public health institutions in the countries and agreed on strategies. Also during this first phase, the networks identified priority diseases and clarified disease definitions; harmonized reporting tools; prepared joint outbreak investigations; and disseminated information through network publications. PacNet demonstrated early success by providing early warnings of dengue, measles, and influenza that led to preventive measures taken across the region. Its early success served as a building block for prioritizing regional surveillance of outbreaks of emerging and re-emerging diseases. Subsequently, all major outbreaks that posed threats to the region were notified and monitored through PacNet. All three networks focused on training health workers in field epidemiology, as the epidemiology workforces in some countries were not fully developed. Many of the individuals who completed the course later went on to lead or play significant roles in their respective ministries/countries; the relationships established during the course fostered the growth of informal, inter-governmental networks and future collaboration. At the same time, individual networks successfully integrated local, national and regional level health officials. These combined capacities and growing trusted relationships further enabled collaboration in preparing for and responding to H5N1, dengue outbreaks, and natural disasters such as Cyclone Nargis that hit Myanmar in 2008 (14). Also during phase 2, network activities moved beyond the health sector to include other sectors at border areas, including customs and immigration (Text Box 2). Through the cross-border sharing of human resources and expertise, the teams participated in a number of joint outbreak investigations. These included a joint dengue fever investigation between the Lao and Thai provincial sites, enabling officials to effectively stamp out the cross-border outbreak; a joint typhoid investigation between the Lao and Vietnam provincial sites; and a joint avian influenza investigation of cases in humans, triggered by the discovery of an infected Lao citizen in Thailand (15). This training enhanced skills in research, outbreak investigation, and communication; and established friendships and trust among officers from adjacent cross-border provinces.

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Bay, San Francisco Bay area; the bay area Belt, if part of name; the belt: Bible Farm Rust Sun but money belt Beltway, capitalized with name; the beltway Bench (see Supreme Bench) Benelux (see alliances) Bible; Biblical; Scriptures; Ten Commandments; etc. Central America Central Europe Central States central time (see time) century, first, 21st, etc. Chairman, Chairwoman, Chair: of the Board of Directors; the Chairman (Federal); but chairman of the board of directors (non-Federal) of the Committee of the Whole House; the Chairman of the Federal Trade Commission; the Chairman Vice chairman, chairwoman, chair (congressional): of the Appropriations Committee of the Subcommittee on Banking but Chairman Rogers, Chairwoman Capito Chair, the, if personified Chamber of Commerce; the chamber: of Ada; Ada Chamber of Commerce; the chamber of commerce of the United States; U. Chief, if referring to head of Federal unit; the Chief: Clerk Forester (see Forester) Intelligence Office Judge Justice (U. Supreme Court); but chief justice (of a State) Magistrate (the President) of Division of Publications of Engineers (Army) of Naval Operations of Staff Christian; Christendom; Christianity; Christianize; but christen church and state church calendar: Christmas Easter Lent Pentecost (Whitsuntide) Church, if part of name of organization or building Circle, if part of name; the circle: Arctic Logan but great circle Circular 420 cities, sections of, official or popular names: East Side French Quarter (New Orleans) Latin Quarter (Paris) North End Northwest Washington, etc. Judicial Conference; Judicial Conference; the Conference Tenth Annual Conference of the United Methodist Churches; the conference Congress (convention), if part of name; capitalized standing alone if referring to international congress: of Industrial Organizations of Parents and Teachers, National; the congress Congress (legislature), if referring to national congress: of Bolivia, etc. Congressman; Congresswoman; Congressman at Large; Member of Congress; Member; membership Conservative Party; a Conservative Capitalization Examples 55 Constitution, with name of country; capitalized standing alone when referring to a specific national constitution; but New York State Constitution; the constitution constitutional consul, British, general, etc. Senate), or to an international court: Circuit Court of the United States for the Tenth Circuit; Circuit Court for the Tenth Circuit; the circuit court; the court; the tenth circuit Court of Appeals for the State of North Carolina, etc. Current, if part of name; the current: Humboldt Japan North Equatorial customhouse; customs official czar; czarist D D-Day Dalai Lama Dalles, The; but the Dalles region Dark Ages (see Ages) Daughters of the American Revolution; a Daughter daylight saving time Declaration, capitalized with name: of Independence; the Declaration of Panama; the declaration decorations, medals, etc. Facebook Capitalization Examples 61 FedEx GlaxoSmithKline Google Hamilton Beach/Proctor Silex, Inc. YouTube First Family (Presidential) First Lady (wife of President) First World War (see War) flag code flag, U. Force(s), if part of name; the force(s): Active Forces Active-Duty Air (see also Air Force) All-Volunteer Armed Forces (synonym for overall U. Constitution; of the Bill of Rights) free world Frisco (for San Francisco; no apostrophe) Fritalux (see alliances) Fund, if part of name; capitalized standing alone if referring to international or United Nations fund: Democracy (United Nations); the Fund International Monetary; the Fund 2 List compiled with cooperation of the U. Government) National and State Governments Printing Office (historical) Publishing Office (see Office) U. Senate or House) Halls of Congress H-bomb; H-hour Headquarters: Alaskan Command; the command headquarters 4th Regiment Headquarters; regimental headquarters 32d Division Headquarters; the division headquarters hearing examiner Heaven (religious); heaven (place) Heimlich maneuver hell (place) Hells (no apostrophe) Canyon Hemisphere, Eastern; Western; etc. Elizabeths (no apostrophe) but naval (marine or Army) hospital hospital corpsman (see corpsman) House, if part of name: Blair Johnson house (private residence) of Representatives; the House (U. League, Urban; the league Legion: American; the Legion; a Legionnaire French Foreign; the legion Legislative Assembly, if part of name: of New York; of Puerto Rico, etc. Congress); the Legislature Ohio Legislature; Legislature of Ohio; the State legislature; the legislature Letters Patent No. Truman; the library of Congress; the Library Hillsborough Public; the library Lieutenant Governor of Idaho, etc. Military Academy (see Academy) Military Establishment (see Establishment) milkshed, Ohio, etc. Mujahedeen mullah Museum, capitalize with name; the museum: Field National National Air and Space; the Air Museum National Museum of African American History and Culture National Museum of the American Indian N Nation (synonym for United States); but a nation; nationwide; also French nation, Balkan nations nation, in general, standing alone National, in conjunction with capitalized name: Academy of Sciences (see Academy) Archives and Records Administration; the National Archives; the Archives Capital (Washington); the Capital; but national capital area Endowment for the Arts; the Endowment Gallery of Art; the National Gallery; the gallery Grange; the Grange Guard, Ohio, etc. Base Guam; the naval base Observatory (see Observatory) Reserve; the Reserve; a reservist Reserve Force; the force Reserve officer; a Reserve officer Shipyard (if preceding or following name): Brooklyn Naval Shipyard; Naval Shipyard, Brooklyn; but the naval shipyard Volunteer Naval Reserve War College; the War College; the college naval, in general sense: command (see Command) expenditures, maneuvers, officer, service, stores, etc. Navy: Admiral of the; the admiral Capitalization Examples 69 Battle Force; the Battle Force; the force Establishment; the establishment Hospital Corps; hospital corpsman; the corps Regular Seabees (construction battalion); a Seabee navy yard Nazi; Nazism Near East (Balkans, etc. Northeast corridor northern Ohio Northern States northerner Northwest Pacific Northwest Territory (1799) Northwest, the (section of the United States) Northwest Washington (see cities) Northwestern: States United States numbers capitalized if spelled out as part of a name: Air Force One (Presidential plane) Charles the First Committee of One Hundred Twenty-third Census (see Census) O Observatory, capitalized with name: Astrophysical; the Observatory Lick; the observatory (nongovernmental) Naval; the Observatory Occident, the; occidental Ocean, if part of name; the ocean: Antarctic Arctic Atlantic North Atlantic, etc. Oceanographer (the Hydrographer), Navy Office, if referring to unit of Federal Government; the Office: Executive Foreign and Commonwealth (U. Public Printer; the Government Printer; the Printer (historical) public utility district (see District) Pueblo, Santa Clara; the pueblo (place); the Pueblo (Tribe) Purchase, Gadsden, Louisiana, etc. Puritan; puritanical Pyrrhic victory Q Quad Cities (Davenport, Rock Island, Moline, East Moline, and Bettendorf) query queue R Radio Free Europe/Radio Liberty Railroad, Alaska; the railroad Ranch, King, etc. Congress); but lowercased if referring to a State senator, unless preceding a name senatorial Sergeant at Arms (U. Senate or House) Sermon on the Mount server Service, if referring to Federal unit; the Service: Extension Federal Mediation and Conciliation Fish and Wildlife Foreign (see Foreign Service) Forest Internal Revenue Marshals National Park Natural Resources Conservation Postal Secret (Homeland Security) Selective (see also System); but selective service, in general sense; selective service classification 1-A, 4-F, etc. Senior Executive service: airmail Army city delivery consular customs diplomatic employment (State) extension (State) general delivery naval Navy parcel post postal field rural free delivery; rural delivery; free delivery special delivery star route Shelf, Continental (see Continental) ship of state (unless personified) Sister(s) (adherent of religious order) Six Nations (see Indians) Smithsonian Institution (see Institution) Capitalization Examples 75 Social Security Administration (U.

Sengers Hamel Otten syndrome

The mean age at diagnosis varies according 134 and fewer salvage resection arthroplasties muscle relaxant use buy cheap nimodipine line. Despite these encouraging recent reports muscle relaxant abuse 30mg nimodipine otc, most orthopedists continue to reserve prosthetic arthroplasty for those patients in whom all other measures have failed to yield relief muscle spasms 72885 generic nimodipine 30mg without prescription. Treatment of symptomatic humeral head osteonecrosis is similar to that described for femoral head osteonecrosis back spasms 39 weeks pregnant 30 mg nimodipine overnight delivery, but because the forces on the shoulder joint are smaller, morbidity is less pronounced (25). A left shift in the differential is usually present in infection, but not in infarction. Positive blood cultures frequently accompany acute osteomyelitis, and a positive culture from local bone aspiration is diagnostic. Radiographs rarely reveal bone changes early on, and the only abnormality may be evidence of soft tissue swelling. Radionuclide bone scans usually do not differentiate infection from infarction in the acute phase (6), but marrow scans may be helpful (28). Intravenous therapy with antibiotics, chosen according to the sensitivity of the organism, is carried out for 2 to 6 weeks, depending upon the nature and extent of the infection. Protected weightbearing and bracing are sometimes required when there is significant bone destruction. Chronic undiagnosed infections may involve bone extensively, resulting in the formation of a so-called "bone within a bone" radiographic appearance, reflecting the presence of a shell of periosteal new bone (involucrum) surrounding a core of dead bone (sequestrum). The prevalence of osteomyelitis may be rare or as high as 61 percent in sickle cell populations (26,27). The predisposition of sickle cell patients to salmonella osteomyelitis is well known. As noted earlier, acute osteomyelitis must be differentiated from acute bone infarction. Although acute bone "crisis" is much more common, a high index of suspicion for osteomyelitis is warranted. Severe pain, tenderness, joint swelling, local warmth, and marked limitation of motion are characteristic findings. Septic arthritis must be differentiated from other types of arthropathy including synovial infarction, synovitis associated with adjacent osteonecrosis, and nonspecific synovitis, which is usually self-limited and rarely progresses to chondrolysis (29). Surgical drainage remains the surest means of completely evacuating exudates and breaking up loculations that may predispose to persistent infection and articular cartilage destruction. Intravenous antibiotics are administered, and short-term joint immobilization is carried out, followed by range-ofmotion exercises. Deformities of the hip in adults who have sickle cell disease and had avascular necrosis in childhood. Radiography depicts the bone abnormalities associated with marrow hyperplasia and those later adaptive changes that result both from remodeling and from growth disturbances. Radionuclide bone imaging is nonspecific and therefore of limited value in differentiating infection from infarction. However, radionuclide marrow imaging has been shown to be useful because it has a high likelihood of depicting diminished uptake in infarction and normal uptake in infection (28). Results and complications of total hip arthroplasties in patients with sickle-cell hemoglobinopathies. Abnormalities of the adult shoulder due to sickle cell osteonecrosis during childhood. Necrosis of the humeral head associated with sickle cell anemia and its genetic variants. Scintigraphic differentiation of bone infarction from osteomyelitis in children with sickle cell disease. Sonographic detection and characterization of musculoskeletal and subcutaneous tissue abnormalities in sickle cell disease. The ulcers usually appear between ages 10 and 50 years and are seen more frequently in males than in females.

Juvenile dermatomyositis

Screening spasms under eye purchase nimodipine in united states online, monitoring uterus spasms 38 weeks order nimodipine 30mg otc, and quarantining of vessels and arriving and departing 80 individuals was instituted at seaports and airports knee spasms at night buy generic nimodipine 30 mg on line. By April spasms lower left abdomen generic nimodipine 30 mg with mastercard, health control measures at border points were increased to include temperature checks for all airport passengers and travelers by land, train, and sea. Additionally, infrared devices were installed throughout points of entry in Hong Kong to assist with temperature screening. On April 17, 2003, the Director of Health, under the authority of Chapter 141 of the Prevention of the Spread of Diseases Regulations, granted immigration officers and members of the auxiliary medical service or civil aid service the power "to stop and detain any person seeking to leave Hong Kong in contravention of Regulation 27A. Further, the Director of Health authorized any "member of the civil aid service on duty to take the body temperature of any person arriving in Hong Kong or leaving Hong Kong. All in-bound, out-bound, and transit passengers had to undergo temperature checks. In-bound and transit passengers had to complete a health declaration stating whether they had fever, cough, shortness of breath or breathing difficulties, and they were required to list all countries and cities they visited within 10 days of their arrival in Hong Kong. Passengers with no fever or other symptoms were permitted to proceed to immigration. Passengers with no fever but other symptoms were advised to consult with a physician and permitted to proceed to immigration. Passengers with fever were sent to an airport medical clinic and were not permitted to proceed unless a certificate declaring them "fit for travel" was issued by a physician. Hong Kong International Airport also implemented preventive health measures in terminals, including frequent air filter replacement, cleaning of courtesy and pay phones, daily cleaning of check-in counters, and sealing of drinking fountains. Additionally, authorities in Hong Kong provided residents with disinfectant to use in their homes. The strategy under the declaration was locationspecific and addressed hygiene standards and measures in various categories and settings, such as the home, food supply, medical, school, industrial, hotel, and sewage. The 81 objectives included setting standards and renewing a culture of public hygiene, instilling a sense of individual responsibility for hygiene, and improving the image of Hong Kong internationally. The role of the teams was two-fold: investigating buildings and drainage and other systems, and taking remedial actions including disinfection, pest control, and cleansing. This group of experts also provided assistance in the implementation of hospital control measures and the enforcement of such measures. A Central Task Force on Supplies was established to track the need for hospital supplies, oversee distribution of supplies, and assess the needs of various hospitals for protective gear and other precautionary items. The Department of Health led the investigation in conjunction with eight other governmental entities. Television, radio, the Internet, and public presentations provided updated information for residents of as well as travelers to Hong Kong. Radio and television announcements and billboards indicated how to wash hands properly, put on gloves, and wear masks. Still, broad-based educational campaigns were not sufficient to ease public fears. After the Amoy Gardens housing complex was quarantined, police discovered that more than half of the apartments were empty with residents having breached the 10-day quarantine order issued by the Secretary for Health, Welfare, and Food. In order to locate the residents who left Amoy Gardens during the quarantine period, the police department formed a task force. Some legal experts maintain that under the Employment Ordinance, "where an employee has contracted the disease, he or she should be granted sick leave by the employer," meaning the employee is entitled to receive payment of four-fifths of normal wages during the leave period. During the height of the outbreak, nearly 60,000 restaurant and hotel workers lost their jobs or were put on unpaid leave. The need to strengthen the public health system and the management of infectious diseases was acknowledged, with "$200 million allocated for treatment of diseases, strengthening infection control, and public education. One committee was to work on overall cleaning campaigns and environmental improvements at housing complexes, another on developing plans and programs for economic redevelopment including promoting tourism, and a third on promoting community involvement in improving the physical, social, and economic environments of the city. Singapore Introduction Singapore is a city-state located in Southeast Asia with a population just slightly over 4 million. Although English is the official language of administration, numerous languages are spoken in Singapore, including Mandarin, Malay, and Tamil. Additionally, health officials in Singapore found evidence that casual contact, such as encounters in elevators, taxis, and hallways, had resulted in contagion. The Cabinet is responsible for the general direction and control of the government, including the administration of the affairs of state.

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