Dr Jonathan Booth

• Consultant Gastroenterologist
• Royal Berkshire Hospital
• Reading

Diagnostic testing for Zika virus: a between faviviruses as determined by cross-neutralization tests postoutbreak update menstrual ovulation calculator buy female cialis 20 mg otc. West Nile virus infection and serologic associated with an epidemic menstruation joint inflammation buy 10 mg female cialis with amex, Yap State menstrual record chart order female cialis 20mg free shipping, Micronesia womens health haven order on line female cialis, 2007 pregnancy 6 days before ovulation generic female cialis 20 mg without a prescription. Original antigenic in urine breast cancer myths generic 20 mg female cialis amex, serum, and saliva specimens from persons with travel sin in dengue. Lack of durable cross-neutralizing antibodies against Zika response in people infected with Zika virus: implications for virus from dengue virus infection. Virus and antibody dynamics in acute West Nile Address for correspondence: Isabel Grifn, Florida Department of virus infection. When the vector of Borrelia recurrentis (Pe diculus humanus lice) was held away from the host for 10 clothes lice (Pediculus humanus), which have also been days, 100% of nymphal and adult lice starved to death and referred to as body lice. Owning 2 sets Stammers Serbian barrels, which were developed during of clothes might be useful; 1 set might be held in a plastic World War I (26), and are still used today in Ethiopia (Fig shopping bag for 10 days to kill lice and their eggs. Lthe spirochete Borrelia recurrentis, once had a cosmo Some of these activities have been part of intentional politan distribution but is now endemic only to countries in schemes to reduce prevalence and intensity of louseborne the Horn of Africa (Ethiopia, Sudan, South Sudan, and So pathogens, but most of these activities have been uninten malia) (1,2). Moreover, some patients with undiagnosed clothes (22,29); it has been reported that clothes lice pre fer a dirty shirt to a clean shirt (30). However, immersion of clothes in water heated Veterinary Sciences, Gatton, Queensland, Australia (D. Leeson of the London School of Tropical Hygiene and Queensland, Australia, and elsewhere for many years (>20 Medicine, who found that when clothes lice were held years for S. This cloth was naturally in fested cloth in several countries and cloth infested in the laboratory with lice and eggs from the Barker isolate of the Culpepper strain of clothes lice. Our experience with clothes lice was similar to our ex perience with head lice; washing infested clothes in warm or cold water for 30 min with or without soap or washing detergent kills few lice and their eggs, although it results in clean clothes, clean lice, and clean eggs. Attacking lice and their eggs in clothes and blankets of persons is a simple way to reduce the prevalence and intensity of louseborne pathogens, such as B. If suc cessful, this strategy might be adapted to other situations in the Horn of Africa and elsewhere, where louse-associated diseases still occur. A) Top view; Thus, we might learn from the scientifc and epidemiologic B) front view showing lid. This 200-L barrel is modeled on the investigations of medical entomologists during World War Stammers Serbian barrels. At other times of the year when it does not rain so heavily and so often, day laborers in Bahir Dah tend to sleep outdoors and, thus, do not have to pay for lodging in boarding houses. It is not known how low hypothesis might be tested in Bahir Dah and elsewhere in the prevalence and intensity of infestation with clothes Ethiopia and the Horn of Africa. Temperature and precipitation data for Bahir Dah, Amhara Region, Ethiopia* Month Variable Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Year Daily 18. First, clothes lice is more accurate low relative humidity caused additional deaths of eggs (41). Moreover, these lice lay most, usually Leeson (41) also showed that 100% of nymphal and adult all, of their eggs in clothes rather than on the body. Treating clothes with insecticides, steam nymphs are especially susceptible to starvation. Even 24 hours without a blood meal will types (sensu bacterial ecotypes) is also controversial. Healthcare clinics in Ethiopia and elsewhere of ing separate species is overwhelming (40), regardless of ten have 200-L steel steaming drums (Stammers Serbian which concept of a species of insect is used. Healthcare and medi interpretation and contextualization of this data by Buxton cal students are instructed in the steaming drum method of (42) and Busvine (30). Mortality rates for the eggs of Pediculus humanus that favorable temperatures for P. Dotted lines denote 12% (top) and 100% (bottom) Leeson (41) showed that relative humidity does not have a mortality rate temperatures. This hypothesis needs to be tested on clothes naturally infested with clothes lice and their eggs in Bahir Dah and elsewhere. Simple experiments on the efect of holding clothes away from hosts for 7 days and for 10 days might be conducted in boarding houses and church dwellings in Bahir Dah, and among day laborers of Bahir Dah and oth er areas in Ethiopia. All nymphal and adult lice would have been gently brushed away so that only eggs are left on the pieces of cloth. In addition, we would repeat this experiment with nymphal and adult lice that were brushed Figure 4. Number of days needed to starve to death adult and from infested clothes onto uninfested cloth (no eggs pres nymphal clothes lice (Pediculus humanus) at 5 temperatures ent). We note also the prospect of treatment with oral iver mectin to kill clothes lice. In with any kind of drug treatment is the cost, immediate and contrast to many other blood-sucking arthropods, eggs of ongoing, to day laborers, street children, and yekolotemar clothes lice die in a few days at temperatures at little lower ies. In addition, resistance to ivermectin might develop in than optimum (Figure 3) (30). Lloyd and Byam (26), Acknowledgment in recounting their experiences as medical servicemen in We thank Richard Pollack and 2 anonymous reviewers for World War I, emphasized constant changing of undercloth providing useful corrections and suggestions and Kostas ing and believed that having 2 shirts rather than 1 helped Mumcuoglu for providing the Orlando strain of P. We extend this idea to all clothes, which in tropical climates, such as in Bahir Dah, means a shirt, underpants and shorts or trousers, and a About the Authors jumper or coat. Barker is a professor of parasitology at the University of not just underclothes, might be infested with body lice. His primary research interests are the biology, evolution, and control of lice Potential Public Health Recommendations and ticks. Barker is a doctoral candidate at the School of Veterinary and live-in-church students in Bahir Dah might be encour Science, University of Queensland, Gatton, Queensland, aged to acquire and keep 2 sets of clothes rather than 1 set Australia. Her primary research interests are the taxonomy of so that at any given time, 1 set of clothes might be kept in a ticks and control of lice and ticks. Antinori S, Mediannikov O, Corbellino M, Grande R, involvement in an immigrant from Somalia to Italy, Parravicini C, Bestetti G, et al. Louseborne relapsing fever in young migrants, in Bahir-Dar, Amhara Region, Ethiopia. Fourth case of louse-borne relapsing fever in fever profle at Felegehiwot referral hospital, Bahir Dar city, young migrant, Sicily, Italy, December 2015: mini review article. Relapsing fever in asylum seekers from Somalia relapsing fever in Bahir Dar city, north-west Ethiopia. A Somali refugee group comparative efcacy trial of three products for the with fever and abnormal blood smear [in German]. Hemorrhagic diathesis in Borrelia recurrentis 1471-5945-10-6 infection imported to Germany. Louseborne relapsing fever among East African lavender oil, eucalyptus oil and lemon tea tree oil, and a refugees, Italy, 2015. Louse-borne relapsing fever: report of four cases in Switzerland, International guidelines for clinical trials with pediculicides. New methods of disinfection for the prevention and 10-year survey of louse-borne relapsing fever in southern Ethiopia: arrest of lice-borne diseases (typhus, relapsing, and trench fevers). The efect of temperature upon the hatching of the eggs School Chemistry and Molecular Biosciences, University of Queensland, of Pediculus humanus corporis de Geer (Anoplura). In nature, the only relevant vector is the body louse, which feeds only on humans; no other reservoir for this infection is known. Bozza,1 Andres Moreira-Soto,1 the Study Alexandra Rockstroh, Carlo Fischer, We prospectively sampled patients in 4 time points up to 90 Alessandra D. The cohort comprised 15 patients with Sebastian Ulbert, Jan Felix Drexler acute Zika virus infection (5 male, 10 female; median age 39. We cannot exclude the possibility of performance of diagnostic tests in tropical areas (7,8). Thus, recent infections with heterologous Research and Education, Rio de Janeiro (F. Drexler); Center for ward, and viral loads in urine were consistently low (Figure Technological Development in Health, Rio de Janeiro (T. Martsinovsky Institute of Medical Parasitology, Tropical and Vector Next, to assess the antibody kinetics of Zika virus Borne Diseases, Sechenov University, Moscow, Russia (J. Limitations of our study include the relatively small number of pa by commercial and in-house serologic tests. All IgM-positive pa public health systems and cohort studies investigating ar tients also showed IgA, which increased during acute bovirus pathogenesis. Reliable testing for favivi Our results highlight that defnite exclusion of acute ruses in such areas will be key for epidemiologic studies Zika virus infections is challenging in a considerable pro on Zika virus and assessments of the safety of favivirus portion of patients. Cross reactivity of commercial anti-dengue immunoassays in patients with acute Zika virus infection. Steinhagen K, Probst C, Radzimski C, Schmidt-Chanasit J, adaptation to severe infections. Assay optimization for molecular detection virus infection in areas with varying past incidence of dengue of Zika virus. Cross-reactivity of antibodies to viruses belonging to the Semliki forest serocomplex. Updated questions and answers Institute of Virology, Campus Charite Mitte, Chariteplatz 1, 10098 related to the dengue vaccine Dengvaxia and its use [cited 2018 Berlin, Germany; email: felix. We studied the clinical manifestations and outcomes of 114 com) automated system for blood culture. We plated pus patients with culture-confrmed melioidosis treated at a ter and tissue on blood, chocolate, and MacConkey agar and tiary hospital in southern India. We summarized descriptive data and analyzed elioidosis is a tropical infection caused by the en the association of patient parameters with outcomes by Mvironmental bacterium Burkholderia pseudomal using logistic regression. Melioidosis is endemic to southeast Patients were predominantly male (92%); mean age Asia and northern Australia; seasonal peaks occur during was 45. Infection is acquired by inhalation, inocu 15 states in India; most were from West Bengal (26. Melioidosis is often difcult to diagnose because of the common risk factors identifed were diabetes mel diverse clinical manifestations, low index of suspicion, and litus (81. Among patients with dia disease remains underrecognized even in endemic coun betes, glycemic control was poor (mean hemoglobin A1c tries. Our study was un cell disease, thalassemia, glucocorticoid use, and liver dis dertaken to delineate the clinical manifestations, antimicro ease (Table 1).

If the service allows for a sliding fee scale menopause zoloft cheap female cialis 20 mg overnight delivery, the family member must qualify according to the same criteria that apply to the general public menopause nausea buy female cialis american express. Staff will not qualify their family member for services at a reduced cost; this must be done by another staff member breast cancer lymph nodes survival rate buy generic female cialis 20 mg line. When a staff member experiences acute symptoms of illness womens health group lafayette buy female cialis 10mg otc, appropriate care and testing will be provided womens health keene nh order female cialis overnight, according to Department capabilities menopause the musical best order for female cialis, and the individual will be referred to a private health care provider. Work required immunizations or lab testing will continue to be provided to employees at no charge. Required physical examinations will be performed at District expense, through a designated outside contractor. Due to the complexity of dealing with government requests, lawsuits and legal actions consult the Deputy District Attorney assigned to the Health District before giving out information, vii) sharing information for health research so long as the client name is redacted and no other personally identifying information is included, viii) it is for workers compensation claims, responding to organ and tissue donation requests from organ procurement organizations, ix) in working with a medical examiner or funeral director when an individual dies. Enforcement of these penalties lies with federal authorities but can include employment disciplinary action, up to and including termination, depending on the situation. In the event a monetary penalty is assessed by the federal authorities against an employee of the Health District, the payment will be the sole responsibility of that person. Civil Penalties: Persons, including health plans, providers and clearinghouses, which violate federal privacy standards will be subject to civil liability. Penalties can range from $100-$50,000 or more for each violation, up to a maximum of $1. Federal Criminal Penalties: Criminal penalties have monetary penalties along with potential jail sentences up to ten years depending on the level of knowledge of the breach of information. All employees are required to follow the Washoe County Information Security Policy located at. Employees shall not engage in any employment, activity or enterprise which has been determined to be inconsistent, incompatible or in conflict with their duties as Washoe County officers and employees, or with the duties, functions or responsibilities of their appointing authorities or departments by which they are employed. Employees shall not engage in any employment, activity or enterprise which is inconsistent, incompatible or in conflict with their duties as Washoe County officers and employees, or with the duties, functions or responsibilities of their appointing authorities or departments by which they are employed, including but not limited to: 1. The use for private gain or advantage of a badge, uniform, prestige or influence of their County positions of employment. The performance of an act in other than their capacity as employees, which act may later be subject, directly or indirectly, to control, inspection, review, audit, or enforcement by such employees or the department by which they are employed. Each appointing authority may determine and describe in writing additional specific activities which, for employees under his jurisdiction, will be considered inconsistent, incompatible, or in conflict with their duties as employees, and shall provide a copy to each such employee. Health District employees who take or teach a class, which is not required as part of their job duties and which requires their absence during normally scheduled work hours shall seek advance written approval from their Supervisor, Division Director and the District Health Officer, and are required to cover the absence with annual or personal leave, comp time, or a flex schedule. Employees, who are taking or teaching a class required by their job, do not need to utilize personal leave or flex schedules, but are required to seek advanced approval from their Supervisor, and Division Director. Employees who are required to take classes to maintain licensure of any kind are required to offset or use leave unless law, ordinance or contract requires otherwise, but are still required to seek advanced written approval from their supervisor and Division Director and the District Health Officer. In all cases, management (Supervisor, Division Director and/or District Health Officer) has the sole discretion to approve or deny the request and whether the employee will be required to use leave or flex time based on the needs of the Department, the impacts on the department, employee scheduling, the availability of leave, employee work performance, and any other factors deemed relevant. The supervisor will review the request with the employee, and if approved, forward the request to the Division Director and District Health Officer for final review and approval. Health District employees have a responsibility to respond to public health emergencies and work outside of the Health District cannot interfere with the employees responsibilities during a public health emergency. Employee is to submit a request for permission to work outside of the Health District to the District Health Officer through their Supervisor and Division Director. Employees name, position, division (within Health District) and program, along with a list of their primary duties at the Health District. Name of company, job title, list of duties and hours for the position desired outside of the Health District. Employee must specify that the 2nd job will not impact their availability or overall ability to perform their duties at the Health District in anyway. An employee can also not accept money or other consideration for the performance of an act which the employee would be required or expected to render in the regular course of hours of their County employment or as a part of their duties as a Health District employee. The notice must inform the employer that the person has been summoned for jury duty and must include a copy of the provisions of subsections 1, 2 and 3. The person summoned, if the person is employed, shall give the notice to his or her employer at least 3 days before the person is to appear for jury duty. The employee must be paid his regular salary while on leave of absence, but must remit to his department head for deposit in the county general fund, all fees which he receives as a witness, juror or when subpoenaed to give a deposition on job-related matters. The Employee may retain amounts received as reimbursement for mileage and per diem. All Health District employees must notify their supervisor of their receipt of a jury summons and submit a copy of the card/letter or document that indicates what date the employee is to report to jury duty to their supervisor at least 3 days prior to the date they are to report for jury duty. Leave without pay taken pursuant to the provisions of the Family and Medical Leave Act (described in Washoe County Code 5. Leave without pay used to create an alternate/adjusted schedule will only be granted in conjunction with an approved alternate schedule request. Employees must submit an Application for Leave/Overtime Authorization form prior to the date of use. All personnel whose position requires a license, certificate, or registration will provide a copy to their Supervisor on or before the expiration date of the previous one. If an employee fails to provide a copy of his or her license, certificate, or registration they will be removed from the work schedule and unable to return until they have provided a copy of their current active license, certificate, or registration. Failure to maintain a required license, certificate, or registration may result in disciplinary action up to and including termination. All long distance telephone calls should be made on the employees assigned telephone line. Collect calls to the Washoe County Health District are acceptable from employees on travel status. Traditional Media (Time-honored media forms) Traditional Media refers to newspapers, magazines, television, radio, billboards, mass transit bus signs, bus shelters, movie advertising, and direct mail. Non-traditional Media Non-traditional Media refers to social media and social media sites including, but not limited to , blogs, mobile applications, Twitter, Facebook, YouTube, Flicker, LinkedIn, MySpace, etc. Paid Media Advertising (Media placement gained by payment) Paid Media Advertising is any form of communication that is gained by payment. Non-Paid Media Earned Media (Acquired as a result of previous effort, action, or payment) Earned Media refers to favorable publicity gained through previous promotional efforts and may include publicity gained through editorial influence. If the Communications Manager is not available, then Division Director or District Health Officer should be contacted for direction. Administrative Secretary Supervisors (to inform support staff, who might receive related calls) vii. All staff must wear attire that is consistent with the personal appearance policy as well as required personal protective clothing and equipment and meet customer facility dress standards. Slacks, Pants, Shorts, and Skorts Slacks that are similar to Dockers and other makers of cotton or synthetic material pants, wool pants, dressy capris, jeans that do not have holes or are not worn out, nice looking dress synthetic pants, and leggings and any spandex or other form-fitting pants that are covered to mid-thigh by a sweater/blouse/shirt or dress are acceptable. When forecasted temperatures are over 74 degrees Fahrenheit: shorts or skorts are allowed in office environment except when meeting with external customers or other Government agencies; and, are allowed during inspections or field work; and when appropriate to wear they dont ride halfway up the thigh while sitting or standing. At no time are shorts or skorts allowed during high risk duties, such as inspecting industrial facilities or visiting construction sites. Skirts, Dresses, and Skirted Suits Casual dresses and skirts are acceptable so long as they dont ride halfway up the thigh while sitting or standing. T-shirts unless worn under another blouse, shirt, jacket, dress (note that t-shirts are allowed while doing field work that does not require interactions with the public); and, 10. Shoes and Footwear Athletic or walking shoes, loafers, clogs, sneakers, boots, flats, dress heels, sandals and leather deck-type shoes are acceptable for work. Closed toe and closed heel shoes are required on inspections, field work and other high risk duties. Jewelry, Tattoos, Perfume, Cologne, Hats and Head Coverings Jewelry should be in good taste with limited visible body piercing and tattoos. Due to allergies perfumes, and cologne, should be worn with restraint or not at all. Hats and head coverings are not allowed unless required for work, religious or cultural purposes, or medical reasons. Hats may be worn outside for sun protection as long as they do not violate other portions of this policy (offensive words, logos etc. If you question the suitability of an item of clothing, do not wear it until you clear it with your Supervisor. If an employee is determined to be wearing inappropriate clothing, management will take action on a case-by-case basis. Employees may use their personal devises without limitations during their lunch or break times. Due to the potential hazards and the increase in power usage; employees are not allowed to utilize space heaters, fans, or other electronic devices not specifically approved or provided by the County. The use of lap tops, note pads, note books, I-Pad, phones, and other electronic devices (whether personal or County owned), for non-business purposes during business hours shall be in compliance with the Washoe County internet and Intranet Acceptable Use Policy. According to the Washoe County Internet and Intranet Acceptable Use Policy approved by the Board of County Commissioners and amended by ordinance #1343 effective July 22, 2002; and Washoe County Code section 5. Employees who choose to bring personal property or equipment onto the County property or in County vehicles do so at their own risk. Each employee shall be requested by their divisions Administrative Liaison to validate/update contact information on a quarterly basis to maintain the departments emergency contact list. Bulk copies should be processed through the Washoe County Reprographics Department, whenever possible. Copies being made for customers who are waiting should take priority over all other copy jobs. The board of county commissioners authorizes the limited use for personal purposes by county officers and employees of county property, equipment or other facility if: (a) the use does not interfere with the performance of public duties including duties of both the officer/employee and other county staff, or interfere with the provision of county services; (b) the cost or value related to the use is nominal; and (c) the use does not create the appearance of impropriety. This section does not prohibit the use of mailing lists, computer data or other information lawfully obtained from a county agency which is available to members of the general public for nongovernmental purposes. Further, this section does not prohibit the use of telephones and electronic mail (e-mail) if there is not a special charge for that use. If there is a special charge for that use, then the use is not prohibited but the officer or employee must reimburse the cost or pay the charge to the county in accordance with subsection 3 below, unless the use is made necessary because the officer or employee is attending to county business. Except as provided in subsection 2 above, if the county incurs a cost as a result of a use that is authorized hereunder, or if the county would ordinarily charge a member of the general public for the use, the county officer or employee shall reimburse the cost or pay the charge to the county. This prohibition includes, but is not limited to: selling products for private business, solicitation related to private business or personal interests, mass mailings, keeping private business accounts, or similar uses. In case of emergency, verbal approval for the use of leave shall be obtained from the Supervisor. Vacation leave and personal leave being requested should already be accrued and reflected in the leave balance on the employees leave bank prior to requesting authorization from the supervisor. Public Meetings, Committees, or Organizations: Employees requesting to attend public meetings or participate as members of committees, or organizations during work hours (which are not required by their position or supervisor) shall submit their written request through the Supervisor and Division Director for approval. The request shall indicate the times, inclusive dates, and reason(s) for the request. The Division Director or designee shall determine whether the request is work related. If the request is not work related, the employee shall submit their request on the leave instrument required within their division through the Supervisor and Division Director or District Health Officer for approval. Employee Association Activities: Release time for Employee Association Activities shall be granted in accordance with the Agreements between Washoe County and the recognized Employee Associations. An employee requesting time shall complete the leave instrument required within their division and shall submit the form through the Supervisor and Division Director to the District Health Officer for approval. In all cases where overtime is necessary, it shall be authorized by the responsible Supervisor before being worked, approved or liquidated by the subordinate employee, unless emergency prevents prior approval. The authorization will include the type of compensation to be received by the employee. Employees are to enter short text in the payroll system for all Overtime or Comp Time Earned. The short text should provide justification for all Overtime and Comp Time Earned. Due to holidays payroll deadlines may be adjusted; employees will be notified of earlier payroll deadlines via e-mail. Supervisor/Division Director or designee is responsible for ensuring all timecards for their staff are entered. If Annual Leave is not available in the employees leave bank, other leave types may be used to fulfill the minimum time requirements for the employee if available. If the employee fails to enter their timecard; their Supervisor should follow up with the employee. Any time that is worked but not entered will need to be entered during the next pay period. Documentation related to grants is maintained for the period required by the grant or the records retention schedule whichever period is longer. Health care records means any reports, notes, orders, photographs, X rays or other recorded data or information whether maintained in written, electronic or other form which is received or produced by a provider of health care, or any person employed by a provider of health care, and contains information relating to the medical history, examination, diagnosis or treatment of the patient. The regular retention schedule, Health District condensed version, and the Health (medical) Records Retention Schedule is available on the Health Public Drive.

It is important to maintain flexibility and creativity as protocols are being developed menstrual wipes cheap female cialis 10 mg on line, as this will maximize effectiveness while avoiding unnecessary expenditures or efforts women's health rochester ny cheap 20mg female cialis otc. For example mensis generic female cialis 20mg with mastercard, seasonal restrictions are best applied in a manner that reflects the dynamics of the natural systems involved menstrual history discount 10mg female cialis visa. Cumulative impacts (a concept often overlooked in mitigation schemes) should be addressed by placing various types of sound exposure into a wider context of animal health womens health network generic female cialis 10mg on-line, reproduction women's health clinic tralee order genuine female cialis on-line, and survival. National regulatory capacity can be improved by better communication and coordination, heightened awareness about sound-related issues, and education and information-sharing efforts. For example, central clearinghouses can make information widely available, educational materials can aid policy-makers, and intergovernmental strategy-sharing can enhance management efforts. The development of public awareness and political will may require a stronger conservation ethic. In all efforts, culturally sensitive approaches that make concerns relevant to the affected parties are likely to be more effective and sustainable. For example, it may be more effective to address the impacts of underwater sound on marine mammals through integration with existing programs to conserve sea turtles in the Caribbean, rather than by creating new, entirely separate marine mammal initiatives in that region. Capacity for oversight, enforcement, and compliance is important at both national and international levels. In some cases, enforcement is complicated by a lack of clarity in existing laws or guidelines. Where existing regulations can be clarified, it may be useful to standardize these and broaden their application. Barriers to ratification and implementation of legal measures may need to be addressed to allow this. There is a general need to develop competency in authorities charged with implementing existing laws. Stronger monitoring and reporting requirements may also help, and monitoring by citizen groups and other users can enhance enforcement capacity. User groups themselves may be more inclined to comply if they have a clear understanding of the problem. Stakeholder participation in policy development and management, as well as education and other efforts to build political will, can also help. Finally, many believe that sound-producing operators working abroad have an obligation to adhere to their own countrys standards when these are more stringent than those of the host country. Finally, a need at both national and international levels is to clarify jurisdictional issues and delineate responsibilities between and within governments. For example, some low-frequency sounds propagate many hundreds of miles and cross multiple jurisdictional boundaries, but the relevant authorities and institutions often lack the capacity to coordinate and cooperate in management. Source-specific and region centered research, as well as improved dissemination of information, may improve understanding of sound propagation and clarify to managers what types and levels of sound are significant. It is also important to improve understanding of the laws that determine jurisdictional boundaries, clarifying ambiguities and educating stakeholders. In addition to the two national/international issues discussed above (numbers 5 and 6), the group identified five categories of actions and tools to improve regulatory capacity at the international level, as described below. There is a need to develop multilateral instruments and guidelines to deal with the issue of sound and marine mammals. Sound can and should be considered an aspect of habitat quality and therefore merits consideration in ecosystem approaches to management. Another area for improvement is in the use of experience and knowledge to shape and inform best practices in permitting, mitigation, or other aspects of management. Improved dissemination of information, job swaps, secondment programs, and model programs also may help. Broad stakeholder participation is another key to improving international regulatory capacity. A variety of formal and informal processes might be employed to achieve this throughout all phases of policy-making and management. Better liability and enforcement mechanisms in existing international law are desirable. These might require statutory changes or legal challenges leading to judicial interpretations. Finally, international use of monitoring and adaptive management would enhance regulatory capacity. Small Group Reporting and Plenary Discussion One participant urged others not to assume anthropogenic sound is a threat to marine mammals without more compelling scientific evidence. Commission on Ocean Policys report as confirmation that marine resources should be available for multiple 87 uses, he pointed out that off California, where low-frequency sound levels have increased by 10 dB over the last 40 years, gray whale populations also have increased. Most notably, the eastern North Pacific population of gray whales is believed to have recovered to a level close to carrying capacity, despite the documented increase in ambient noise. Another participant elaborated on this point, suggesting that even if one accepts that anthropogenic sound is a problem, the resources committed to address it may be currently misallocated. Several participants expressed disappointment that the very existence of a problem is still a matter of debate. They suggested it was simplistic to infer from the evidence of population increase for some marine mammal populations that exposure to anthropogenic sound poses no threat. If the best available scientific opinion indicates that there is a problem, a precautionary approach would be to accept the need for corrective action (mitigation) while at the same time pursuing focused research to improve understanding of the nature and magnitude of the problem. Common themes from the group reports and ensuing discussion included that (a) both short and long-term goals and objectives need to be defined and clearly articulated; (b) outreach and education should begin immediately; (c) management of sound should be tailored appropriately to the type of activity involved, and (d) given that the shipping industry has its own economic (energy-conservation) reasons to move toward quieter ships, there may be opportunities for cooperative action. Table 2 (see page 72) provides a summary of multilateral agreements mentioned in the workshop proceedings. Synthesis, Summary, and Future Directions Mark Tasker provided a personal synthesis to initiate the workshops final plenary discussion. The overall goal of policy is to reduce and further control anthropogenic sound in the worlds oceans. The greatest concern is loud low and mid-frequency sound, the most significant sources of which are shipping, seismic survey operations, and military sonar. Views differ concerning the relative and absolute significance of sound as a risk factor for marine mammals. Some participants likened the current debate on this issue to the early stages of the controversy over global warming. It is important, however, to continue to seek greater agreement on the environmental effects of underwater sound because any action to manage sound will cost resources. Given that resources are limited, any allocation to address one sound source could have implications for the amount available to address others. Thus, to some extent at least, attention and investment devoted to the sound issue may divert resources away from other conservation issues. Rapidly growing awareness of the problem of sound and marine mammals on the part of those involved in sound-generating activities creates opportunities for action. For education and outreach, materials and campaigns need to be carefully crafted and culturally sensitive, and public input is therefore essential. The primary aim should be to ensure that the issue is widely debated and placed on relevant agendas. Educational efforts 67 Report of an International Workshop: Policy on Sound and Marine Mammals need to be grounded in accurate reporting, with uncertainties explicitly acknowledged. Tasker believes that the military has made good progress but needs to be more transparent. The seismic industry has guidelines, but those may need to be open for comments and modification. Industry should be encouraged to continue development and testing of mitigation approaches (noting the considerable investment that has already been made). The shipping industry and ship designers should be challenged to develop quieter technology. In terms of legal frameworks, it is necessary to consider scale and transboundary aspects. In general, it will be necessary to choose between prescriptive and performance-based models, but the latter is preferable. It was agreed that sound should be incorporated as an element to be considered in environmental impact assessments. Internationally, the creation of a new treaty on sound and marine mammals would be hard to deliver. Acceptable risk is a cultural choice, and thus universality may be difficult to achieve. A code of conduct for sound-generating ocean research is being developed in Germany. The workshop goals of (a) describing the range of existing management and mitigation approaches and (b) exploring and describing cross-boundary issues were largely met. The goal of identifying strategies and solutions to policy questions that might be transferable across national boundaries was met only partially. It might be useful to hold further meetings as offshoots of this workshop, focusing on some of the technical issues identified in London. Such meetings might include more case studies in which the entire management process is tracked from problem identification, to directed research, to management decision-making, to implementation. Selected Examples of Domestic Laws and Regulations Mentioned the examples provided are a subset of those discussed during the workshop. Country Sound Sources Relevant Laws or Means of For additional information Potentially Regulation Addressed Brazil Seismic survey Resolution 305 of the National. Summary of Multilateral Agreements Mentioned the agreements summarized below are those mentioned in the workshop proceedings, a subset of those discussed during the workshop. Agreement Agreement Name Date Date For more information Abbreviation Signed Entered into Force Abidjan Convention for Co-Operation in the 1981 1984 hq. Ocean ambient sound: comparing the 1960s with the 1990s for a receiver off the California coast. Acoustically enhanced bubble growth at low frequencies and its implications for human diver and marine mammal safety. Manuscript circulated at workshop by Wolfgang Dinter on behalf of the Federal Agency for Nature Conservation/BfN (Germany). Available from: Bundesamt fur Naturschutz (BfN, Federal Agency for Nature Conservation), Konstantinstrasse 110, D-53179 Bonn, Germany. Guidelines for minimising acoustic disturbance to marine mammals from seismic surveys. A call for research to assess risk of acoustic impact on beaked whale populations. Available from the office of the Journal of Cetacean Research and Management, the Red House, 135 Station Road, Impington, Cambridge, U. The workshop results will be used to inform the deliberations of the Commissions Advisory Committee on Acoustic Impacts on Marine Mammals, and ultimately, policy-makers in the United States Congress and around the world. How are those countries alike or different in their approach to protecting marine mammals and/or regulating anthropogenic sound production What limitations do these countries face in dealing with the impacts of sound on marine mammals Has sound or acoustic impacts on marine mammals been effectively addressed by international law or institutions Are there short or long-term actions that could be taken in international fora to address this issue National Oceanic and Atmospheric Administration Office of International Environmental Law What steps can be taken to analyze existing legal frameworks, examining their applicability to the issue of acoustic impacts on marine mammals What steps can be taken to analyze potential short and long-term actions that could be pursued in international fora to address this issue What steps might be possible to further the discussion of this issue in relevant international organizations/institutions and what types of actions could be taken in international fora or through international legal instruments to address the issue How are the effectiveness and efficiency of mitigation strategies and impact assessment evaluated What can we conclude about effective management, impact assessment, and mitigation strategies What differences exist between countries in their national approaches to risk assessment How can we define a "precautionary approach," and when/how should such an approach be applied in policy National Marine Fisheries Service What constitute state-of-the-art, best practices in mitigation How do strategies differ for naval sonar, seismic research, shipping noise, and other sound sources To what extent are mitigation strategies, monitoring technologies, and other techniques transferable across sound sources To what extent do we understand the effectiveness of existing mitigation techniques Group B: Best practices and emerging techniques (new applications of technology; research and development; standards for application of mitigation strategies; etc.

The above completion of the appropriate courses are required additionally applies to non-human primate within the first month of work at Stanford University menopause the musical san francisco discount female cialis american express. This course is Bloodborne Pathogens training even if they will not entirely web based and requires annual updates be potentially exposed to bloodborne pathogens menopause keene nh buy female cialis 20mg otc. Simple Sketch of Droplet & Airborne Virus and Bacterial Transmission Credit: Ian M menstrual wheel order 10mg female cialis with visa. Droplet spread organisms can only contamminate nearby air See the Stanford University Biosafety home while airborne organisms can contaminate over a much wider area menopause 55 plus purchase female cialis 20mg visa. In addition pregnancy fruit comparison cheap 20mg female cialis with visa, the employer is Safety/Medical Monitoring menstrual kits buy cheap female cialis, Aerosol Transmissible required to develop, implement, and annually review Disease Program. The Stanford Review the Plan annually or when changes are made University Administrative Panel on Biosafety (new personnel, procedures, etc. Chapter 6: Training 57 and to be made readily available to authorities in the event of a regulatory inspection of the facility. Review the Plan annually or when changes accidental spills and personnel contamination are made (new personnel, procedures, etc. This includes the Stanford University Additional information along with the plans and Local Exposure Control Plan ehs. Disease Plan (if appropriate, see above) and training suitable for each individual. In a laboratory environment, the type of experiments being conducted, nature of the material used, and the equipment used would determine the required types of training. If required, training and certification for shipping of dangerous biological materials and/or dry ice must be completed. The Biosafety group ofers a number of live and on demand Information Sessions to better suit your Power Failure particular needs and that of your lab / facility (Figure Consider where your biological materials are stored 3); these can be done at a lab group meeting or any and what equipment contains such materials. A request for any of the above Information Earthquake Sessions can be done simply by going to the Shaking may cause containment to be compromised. You cannot see what biological material may Medical Emergencies: be present in flood water. Do not step into water When working with biological material, consider since hazards are unknown. Plan for the following what information would be helpful to those assisting situations: the injured. Whether you want us to drop by a lab meeting, or meet you for a cup of coffee at Coupa, wed love to talk. Health this includes those who work with purposefully Surveillance inoculated animals, as well as those that work with animals that may be infected with zoonotic agents not related to the research, such as sheep whose body fluid may contain Coxiella burnetii, the causative agent for Q-fever. The Medical surveillance examinations may be required Occupational Health clinic will provide medical for researchers who work directly with biohazardous clearance as indicated to the requesting agents. Chronic hepatitis B virus infection is a long-term illness that occurs when the hepatitis B (650)723-5111 virus remains in a persons body. Most people who go on to develop chronic hepatitis B do not have Hepatitis B Vaccination Program symptoms, but it is still very serious and can lead to liver damage (cirrhosis), liver cancer, or death. Chronically-infected people can spread hepatitis B virus to others, even if they do not feel or look sick themselves. People human or non-human primate blood, body fluids or any other substances covered by the Bloodborne Pathogens program can become infected with the virus through: birth (see Chapter 6) as a part of their work at Stanford University (a baby whose mother is infected can be infected will be ofered the Hepatitis B vaccine at no cost to the at or afer birth), sharing items such as razors or employee. Hepatitis B or other drug-injection equipment, or exposure to can cause mild illness lasting a few weeks, or it can blood from needle sticks or other sharp instruments. Hepatitis B virus Occupational exposure can occur through a infection be either acute or chronic. Hepatitis B can cause 2 Hepatitis B vaccine mild illness lasting a few weeks, or it can lead to a serious, Hepatitis B vaccine is made from parts of the hepatitis B lifelong illness. Acute hepatitis B virus infection is a short-term illness Infants should get their frst dose of hepatitis B vaccine that occurs within the frst 6 months after someone is at birth and will usually complete the series at 6 months exposed to the hepatitis B virus. Department of Health and Human Services Centers for Disease Control and Prevention Figure 2. Hep B Vaccine Information 66 Stanford University Biosafety Manual Hepatitis B vaccination can prevent hepatitis B are performed for those working directly with the and its consequences, including liver cancer and agents; those working in proximity but not directly cirrhosis. While Stanford University encourages employees to be vaccinated, accepting vaccination is not a condition of employment. The Stanford staf, students and visiting scholars who work University Occupation Health Center medical staf, directly with vertebrate animals, unfixed animal in conjunction with the Administrative Panel on tissues or body fluids, and those who work in Biosafety and the Biosafety Oficer, will make the animal housing areas. This program is authorized recommendation for the use of vaccinations on a by federal regulations and Stanfords external case-by-case basis. University policy requires that all faculty, staf, or in-person evaluation in the Occupational Health students, and visiting scholars who work directly Center. Researchers for research and teaching individuals during working with other hoofed mammals. Continuing authorization to use animals are variable and dependent upon specific uses is contingent upon the potential requirements to and handling identified in the animal care and use participate in the program. Animals in Risk Category 1 v Risk Category 2 Risk Category 1 Risk Category 2 Non-Human Primates Dogs Sheep (Female/Neonatal) Rabbits Pigs Rodents (Domestic/Captive) Goats Sheep (Male) Bats Marine Mammals Birds Fish/Amphibians/Reptiles Wild Animals Or Animal Field Studies upon identified risk factors. The symptoms are generally evident six educational materials and periodic updates on to 24 months afer exposure but sometimes may potential health and safety issues associated take years to develop, and ofen worsen over time. Many of those reactions to most other species, including hamsters people can change career tracks or be reassigned to and ferrets, afer chronic exposure. Standard allergy shots the actual allergens are proteins in the saliva, which (immuno-therapy) to reduce allergic sensitivity to are present on the animals skin and hair. If avoidance is impossible, its critical that found in soiled bedding, and may be distributed as exposure is minimized as much as possible. An can give temporary symptomatic relief, it is understanding of the proper use of ventilated best to seek the advice of a physician before workstations will help minimize aerosol exposure self-prescribing. Biosafety is ofen consulted as those listed above) should be followed by all for help with risk assessments. Current federal guidelines require that all health history might afect travel recommendations. Clear procedures the Ofice of International Afairs should be established in each facility for reporting international. These risks can include animals in the area, endemic infectious Chapter 7: Surveillance 71 Figure 6. Examples of Potential Travel Related Medical Considerations Specific medical recommendations to be determined post consultation. Personnel engaging in travel and field dust or debris potentially containing dried feces work are advised to be aware of their surroundings, or urine, or a need for increased protection from availability of local health care, and any specific allergens during animal work. Specific quarantine Pregnancy Planning measures may need to be implemented for any Some infectious agents pose a particular wild animals brought to vivarium or other housing reproductive risk around or during pregnancy. Some agents pose a risk if contracted need permits for importation, even if live animals during pregnancy; others, like Zika Virus, pose a risk are not present. Contact Biosafety for further if contracted during pregnancy but can also pose a information regarding the specific requirements for risk if a partner was exposed prior to pregnancy and your particular work. If you have questions or concerns about the nature of your work, please consult Biosafety by calling 725-1473. For health concerns, Important Information please call the Occupational Health Center at 725 Reproductive Health 5308. One typical the goals of this program are to protect the example of this is the need to wear an N95 respirator. In general, the biosafety level recommended for working with infectious agents in vivo is the same as that for working with the agents in vitro. Animal Biosecurity Animal Biosecurity is a set of preventative measures designed to reduce the risk of transmission of infectious agents among animals or between animals and humans. It is a designation determined by the Veterinary Service Center and supported by Biosafety. This designation includes agents that may not be an infectious risk to humans but are animal pathogens, as well as zoonotic agents that have the potential to spread among both animals and humans. Animal Biosafety Levels Animal Biosafety Animal biosafety levels, similar to biosafety levels, provide increasing protection to personnel and the environment. These levels are the general minimum requirement for work with exposed laboratory animals. It Animal housing is done at the appropriate animal builds upon the practices, procedures, containment biosafety level. If it is confirmed you will Work with biohazards in animals requires approval need a protocol, you can file a tissue-only protocol. Additionally, personnel are there is the concern of transmission among a required to complete a tour and orientation of the susceptible animal colony, and these agents fall facility to which their animals are assigned. Field Work Wild animals pose additional zoonotic risks, as their the use or proximity to animals and potential health history is unknown. These tests are done to detect specific agents, and may not identify all possible zoonotic risks. Engineering controls include items such as biosafety cabinets, ventilation systems, Safety: Practices closed top centrifuge rotors, etc. Biosafety is a two-way path involving the creation of a safe working environment for all personnel and Personal Protective Equipment ensuring that the work being done does not impact the environment. When properly to the wayside in the presence of a worker who is selected and used, personal protective equipment ignorant or uncaring of proper work procedures. The following are some of the more common available, and that employees have received the accidents that can result in infection: necessary training. Stanford University provides Chapter 9: Safety: Practices and Equipment 87 Figure 1. Speciality Gloves Recommended Biosafety ofers assorted specialty gloves for research Biological Safety/Biosafety Cabinets personnel to try while being hands on with their experiments. Engage and prepare the patient and work area with safety features on sharps devices. Support for printing this poster came from an unrestricted educational grant provided by Safety Institute, Premier, Inc. Protect yourself and others, use sharpes with safety features 90 Stanford University Biosafety Manual Figure 4. Liquid Waste the lef suction flask (above lef, A) is used to collect the contaminated fluids into a suitable decontamination solution; an example setup of this is photographed in (middle), an alternate setup shown in (right). The material the cabinet, or if the chemicals or radionuclides will (research experiment) inside the cabinet is not not interfere with the work when recirculated in the protected and thus subject to contamination. This cabinet is acceptable for use of low to moderate risk agents in the absence of volatile toxic chemicals and volatile radionuclides. Do not block the perforated grills at the front and rear of the biosafety cabinet. The biosafety cabinets air Use of Open Flames in Biosafety intake is dirupted by blocking the grills. Blocking the Cabinets/Tissue Culture Hoods grills at the opening of the biosafety cabinet may also allow contaminated room air from entering the cabinet Background without filtration. Early microbiologists had to rely on open flames to Do not store unecessary equipment or supplies in the ensure sterility while engaging in certain techniques. With the advancement of modern technology, Do not use the top of the cabinet for storage. In fact, the use of open flames in a airflow, thereby efecting performance and endangering Biosafety cabinet the researcher or the experiment. Universal Precautions Biohazard Signage For information regarding Universal Precaution signs, see Chapter 4. There are many alternatives to the use of Electrical components such as the fan motor, burners: microincinerators, disposable tissue culture lights and electrical outlets are not designed to supplies, etc. Use only enough alcohol for one accordance with recommendations from numerous days work agencies. The use of such devices is not only extremely 94 Stanford University Biosafety Manual Figure 8.

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