By G. Mamuk. Antioch University Santa Barbara.

Further research is particularly needed in these areas buy generic zestoretic pills, including clarification of what is being evaluated and the use of guiding principles for evaluation; the development of the theoretical underpinnings of the concept and methodological rigour; exploration of any unintended campaign effects and campaign cost effectiveness; and the promotion of detailed reporting of methodologies used [8] discount zestoretic online american express. The evidence base for health communication for non-communicable diseases is perceived in some instances to be more developed than that for communicable diseases [4 generic 17.5 mg zestoretic mastercard, 5] purchase zestoretic on line. Specific instances of this include the evidence base in health advocacy and the work in progress on behavioural determinant mapping in non-communicable diseases [2, 5]. The European knowledge base may be usefully developed with reference to those in other jurisdictions and in relation to other disease groups. These evidence bases may provide a useful resource for the further development of a knowledge base for health communication for communicable diseases. The opportunity exists to explore the transferability of the expertise, capacity, information and best practice developed with regard to non-communicable diseases to communicable diseases. Interestingly, it was suggested during the stakeholders consultation that the distinction between communicable and non-communicable diseases was not a useful one as many non-communicable diseases are caused by infectious agents [2]. The need for more, systematic evaluation was repeatedly identified during this research project in relation to formative, process, impact, outcome and cost-effectiveness evaluation [4, 5, 8]. Evaluations can identify the significant and appropriate expectations of an initiative, the most effective strategies, and may support the development of best practices [32], serving to keep an initiative on track or, alternatively, indicate when it is advisable to adjust or adapt the advocacy strategies. The importance of an inclusive approach to meaningful evaluation [33] was also highlighted [5] in order to identify whether the intended beneficiaries of the advocacy intervention perceived a benefit from the initiative [32]. An initiative which brings about a change of policy or legislation will be of little real value if those for whom the change was intended to benefit do not know that this change has come about or if they are unable to access the legal services to vindicate their rights [33]. Recent developments have strengthened the knowledge base for health advocacy evaluations, and strong recommendations exist about the importance of the use of a theory of change during the development of campaigns and initiatives to make explicit the intended relationship between actions and outcomes [5]. The emerging knowledge and resource base might be profitably utilised in the wider development of evaluation of health communication interventions for the prevention and control of communicable diseases in the future. A number of issues were highlighted as priorities, including developing an evidence base for the use of new and social media channels, profiling and targeting audiences, and retrospective evaluation on the use of health communication in recent crises in order to inform proactive planning for future crisis events. Evaluation is particularly underdeveloped in the broader context of health communication, and scant in relation to health communication for the prevention and control of communicable diseases. Integral to the development of more formal evaluation is progress in identifying the indicators of success for health communication activities. Promisingly, the evidence base is increasing and, for example, there are a number of guides and toolkits about theory-based evaluation of health advocacy interventions that can guide further advances in this sphere [34, 35]. A platform to support the development and sharing of evidence, tools, experiences and outcomes would greatly facilitate the development of the field of health communication. Interventions and activities can be accessed from such a database and tailored to suit the needs of the topic, country and target group. Such an approach would also strengthen the consistency of health communication for prevention and control of communicable diseases in Europe. A particular value of such a platform may be the sharing of evidence and experience in relation to poorly reached groups. For example, a number of European countries have a significant Roma population, and the learning achieved in one country from a campaign to target the Roma population may provide an invaluable basis to inform a campaign with similar objectives in another country. Likewise, religious influences on the uptake of particular health services or health interventions may impact consistently on communities of that faith in whichever European country they live, and therefore, evidence gathered in one jurisdiction might usefully inform development and practice in other jurisdictions. The current status of health communication campaign evaluation demonstrates the need for capacity building within and across European countries. Such capacity building can be enhanced and/or promoted through the identification of the skills and knowledge of researchers and health professionals who have worked in this area. Encouraging and facilitating open dialogue to exploit the lessons that may have been learned but not documented may also contribute to capacity. More extensive and detailed publication of process and impact evaluations would usefully contribute to the ongoing development of policy and practice [6]. The consultations identified a desire among the stakeholders for the development of a more reciprocal relationship between those working in the area of health communication and transnational agencies. Workforce The availability of qualified human resources with sufficient skills and knowledge and the availability of training options. The challenges and opportunities offered by the diversity of the workforce involved in health communication for communicable diseases in Europe were highlighted earlier. Health communication competencies may be defined as the combination of the essential knowledge, abilities, skills and values necessary for the practice of health communication (adapted from [36]). Overall, stakeholders considered that education and training for health communication in the prevention and control of communicable diseases is currently underdeveloped across Member States [1-3]. It is important that, in consultation with Member States, research is conducted to establish the core competencies required for health communication so as to clarify the focus of the education and training provision. A number of key skills deficits were identified in the stakeholders consultations. One was around evaluation research, which was perceived to require specific skills and resources. The types of evaluation reported in the data collection suggest that participants are at least familiar with outcome, impact and cost- effectiveness evaluations. A second area of concern to the stakeholders was in the use of media in general, and specifically new media and new technologies. Because of the variability between countries in their capacity to develop and effectively use health communication activities, any strategic development at a European level must be cognisant of this discrepancy in capacity and experience. Effective guidelines and tools to support health communication in a consistent way will be of significant value. During the consultation, the stakeholders identified a number of specific training needs, including in the area of social media, evaluation, and public relations in order to be prepared to deal with the media, particularly in crisis situations. A particular challenge of social media was identified as its speed, requiring health communicators to respond immediately to issues in order to pre-empt the dissemination of misinformation and also to react immediately to counter any misinformation that has already been disseminated [3]. In the absence of relevant training or education courses, such courses might usefully be developed. The range of communicable diseases was, in itself, seen as a challenge to professionals working in the area of health communication; particularly emerging diseases that are new to Europe, such as West Nile virus and chikungunya fever. A database of resources developed during the Translating Health Communication Project may represent a first step towards the establishment of a research and knowledge infrastructure that can support professionals. The database records link to over 600 resources for communicable disease topic areas with information about the target audience of the resource, the organisation that developed the resource, the language of the resource, and the date it was developed. It also includes a further category which logs a diverse range of 49 health communication and information portals and websites. This database, while not designed to constitute an exhaustive list, nor act as a compendium of best practice examples, aims to facilitate improved sharing of online health communication resources and materials between European countries and regions. A wide range of expertise is evident among identified stakeholders working towards the prevention and control of communicable diseases [1]. Health communication is often one part of the overall remit of such experts, particularly in countries with smaller populations. Stakeholders identified that structured health communication training was required and suggested that European-level organisations should coordinate and facilitate such training. A scoping study of education and training courses that currently exist would prove a useful preliminary to this endeavour. Collaboration with the higher education sector could advance the development and uptake of education and training opportunities including continuing professional development. A wide variety of professionals are involved, to varying extents, in health communication, but there is a lack of clarity and little consistency about where the responsibility for health communication lies in individual countries. At present, the organisational structures do not support high levels of strategic planning or collaboration. Stakeholders suggested that the focus of health communication was on crisis rather than planned communication. However, it is also clear that the key stakeholders, as represented in the consultation phases of this project, are committed to the development of health communication for communicable diseases. They identified the need for a coherent and coordinated approach to build on the expertise, knowledge and evidence that currently exists to enhance health communication to improve health and reduce health inequalities. Stakeholders also identified the need for a shift from a top-down approach to a more participatory, citizen-centred way of working. The utilisation of new digital media, such as social media, to deliver timely and relevant health messages and to dialogue with citizens was also widely recognised as an emerging opportunity. Some of it pertains to health communication for communicable diseases but much relates to non-communicable diseases. This evidence represents a resource that can be mined to establish its relevance and transferability to health communication for communicable diseases in the European context.

All estimates will be generated with 1000 (or more) draws of the quantity of interest from the posterior distribution cheap zestoretic 17.5 mg visa. Where possible purchase discount zestoretic online, we will demonstrate validity of the statistical methods by using out-of-sample prediction order 17.5 mg zestoretic visa. Disability weights will be based on samples of the general population using methods with valid psychometric properties buy cheap zestoretic 17.5 mg line. Given the complexities of the estimation process timelines may shift, though for illustrative purposes the following table provides the envisioned schedule. When specific countries 11 or relevant policy actors ask for tabular results for policy formulation, we may make this available ahead of the general public, as an essential means to help fuel the use of the results for policy formulation. In addition, an Independent Advisory Committee has been assembled and is chaired by Dr. Council members who are unable to attend will have 72 hours to provide feedback and/or votes by email. Majority vote prevails; eligible voters are those that are present at the meeting and those that respond with votes by email within 72 hours. The Council Chair will be responsible for producing the agenda for each Council meeting. Therms may be truncated for any Council members inactive for greater than a 6 month period. Referrals and nominations for Council members are welcome and should be sent to the Council Secretary. The Senior Leadership is appointed by the Principle Investigator and provide direct oversight to the estimation 2. These Core Analytic Theam members will be primarily responsible for identifying data sources used, applying the relevant methodologies, systematically documenting sources and approaches, and producing and vetting results for each year’s update 3. Analysts for Central Computation: a team of analysts will be responsible for managing, implementing, and developing the complex central machinery for computation 4. Systematic Review Group: to support the ongoing data needs, a team will continually conduct systematic reviews of the published and unpublished literature, as outlined in the “Data” section below. Analysts for Central Database Management: A team of analysts will seek data and manage core central datasets and databases, such as the covariates database, cause of death database, epidemiology database, risk factor database, hospital and outpatient datasets, cancer and other disease registries, household surveys, and many other data source types. More details specific to each of these types of experts are provided later in this section. Legitimate scientific debate may arise across different mortality, disease, injury, risk factor, and country experts; disagreements regarding any aspects of the analyses should be addressed following the protocol outlined in the “Adjudication” section below. Referrals and nominations are welcome and should be sent to the Management Theam; there will additionally be an open call for applications from interested experts that will be published in The Lancet. A point of contact for the Management Theam will be listed on the study website: www. Note that manuscripts may not be published prior to the capstone papers Publication May 3, 2014- Once the capstone papers are published on May 3rd, September 3, 2014 publication of additional manuscripts is welcomed. See the “Data” and “Publications and Presentations” sections below for additional information. These areas of contribution will be for specific diseases, injuries, risk factors, or impairments. February 1, 2014 Deadline for returning all final feedback to the Core Analytic 21 Theam member(s). Note that manuscripts may not be published prior to the publication of the capstone papers. Publication May 3, 2014- Once the capstone papers are published on May 3rd, September 3, 2014 publication of additional manuscripts is welcomed. See the “Data” and “Publications and Presentations” sections below for additional information. Publication May 3, 2014- Once the capstone papers are published on May 3rd, September 3, 2014 publication of additional manuscripts is welcomed. See the “Data” and “Publications and Presentations” sections below for additional information. They hold the ultimate responsibility for reviewing and approving the final results. Independent Advisory Committee An external advisory body has been created and will be led by Dr. The inaugural Chair of the Independent Advisory Committee for the Global Burden of Disease is Dr. The King Baudouin Foundation will host and facilitate the Independent Advisory Committee. Data sources with implausible patterns relative to other related sources may be excluded from the analysis. Differing opinions may arise on which data points should be excluded from the estimation process. Disagreement about estimates for a particular disease, injury, risk factor, or impairment: Within a given disease, injury, risk factor, or impairment there may be disputes about the estimates of overall prevalence, by age, or by sex. Disagreement about a particular geography: Differences in opinion regarding estimates, data sources, and/or approaches for a particular country may arise. Since the modeling effort is focused on specific diseases, injuries, risk factors, and impairments, the total picture for a given geographic region is dependent upon the sum total model outputs. Data are not equally available for all diseases, injuries, risk factors, and impairments for all geographies. Model performance may not be the same for all diseases, injuries, risk factors, and impairments for all countries. Similarly, methodological experts and country experts may have differing opinions about the level of all-cause mortality for a particular country. Adjudication process To resolve such disagreements, steps should be pursued in the following order: 1. For any of the types of disagreement, resolution should first be sought through discussion between the individuals with differing opinions. We believe that the majority of differences in opinion can be managed in this way, resolved through the usual process of scientific testing and iteration. This will be especially true in instances where the dispute is about the inclusion of data or of the effects of different analytic strategies, as each of the different viewpoints can often be tested and the results compared with one another. We expect that such discussions will take place in a spirit of respectful academic disagreement. In such cases, the rationale for the final decision taken should be made explicit to all individuals formerly in dispute. In this scenario, the involved individuals should attempt to jointly reach a resolution. The text below the flowchart provides additional detail and is numbered to match the numbered component(s) of the flowchart it describes. This estimation task is facilitated by the use of appropriate covariates that can be 25 used as independent variables in the modeling process. For each covariate in our covariate database we have a complete time series for each country, and by age and sex, where appropriate. In cases where the development of a new covariate requires new research, such covariates will only be made public after that research is published. Incorporated into this database are all relevant sources of cause of death data, including vital registration, verbal autopsies, census and survey data, police records, hospital data, surveillance systems, and population based registries for specific diseases. Ensuring consistency between cause-specific estimates and all-cause mortality estimates In accordance with the published methodology, models will be developed for each cause of death separately; the estimates for each cause will then be combined into estimates for all causes 26 simultaneously that sum to the demographic estimates of all-cause mortality. Key inputs into this database include systematic reviews of the published and unpublished literature, analysis of household survey data, antenatal clinic surveillance data, reportable disease notifications, disease registries, hospital admissions data, outpatient visit data, population-based cancer registries, active screening data, and other administrative data. In each case, the quality and extent of data on the overall impairment level has been determined to be stronger than the data on how individual etiologies or conditions lead to that impairment. Attribution to each underlying cause of the impairment will be performed after calculation of the total envelope for that impairment. Each injury is characterized by the nature of injury such as a femur fracture or head trauma and the external cause of injury such as a road injury or a fall. To assess disability, data are required on the frequency of the nature of injury as well as follow-up data on reduced health functioning at certain points in time after the injury.

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In areas where people customarily boil the plants or their “fruits” (water chestnuts) before eating them but give them raw to swine buy generic zestoretic 17.5 mg, the infection rate is much higher in these animals than in humans buy zestoretic overnight delivery. In general safe zestoretic 17.5 mg, the preva- lence of human infection is higher in areas where the aquatic plants are cultivated and lower in distant towns order zestoretic with a mastercard, since metacercariae attached to the plants are not resistant to desiccation when some time elapses between harvest and marketing. The pig is con- sidered a reservoir of the parasite that could maintain the infection in the human pop- ulation even if the sanitary elimination of human excreta were achieved. In Muslim countries, such as Bangladesh, swine do not play any role as a reservoir; man is prac- tically the only reservoir and only source of infection for snails (Gilman et al. The infection can be imported by patients into regions where intermediate hosts exist; one study found that 3 of 93 Thai workers in Israel were infected by F. The eggs are very similar to those of Fasciola gigantica and Fasciola hepatica; experts say that the eggs of F. There are no reports on attempts at immunological diagnosis, but the parasite has shown cross- reactions in tests for Fasciola hepatica, the larva of Taenia solium, and Trichinella spiralis. Control: The simplest way to prevent human parasitosis is to refrain from eating fresh or raw aquatic plants, peeling them with the teeth, or drinking water from con- taminated areas, but this recommendation requires changing a habit, which is diffi- cult to achieve. Studies conducted in China have shown that immersing contami- nated plants in boiling water for 1 to 2 minutes is sufficient to kill the parasite. Other measures to combat the parasitosis, in addition to health education, are to use mol- luscicides, to treat the affected population, to treat the human excreta in septic tanks or with quicklime, to prevent the fertilization of fields with human feces, and to pro- hibit swine raising in endemic areas. Larval stages of medically important flukes (Trematoda) from Vientiane province, Laos. Etiology: The agent of this infection is Gastrodiscoides (Amphistomum) hominis, a bright-pink, pear-shaped trematode 5–14 mm long by 4–66 mm wide; it lives in the cecum and ascending colon of swine and humans, although it has also been found in monkeys and field rats (Soulsby, 1982). The anterior part of the parasite is conical, but the posterior opens into a disc with a suction cup. The eggs leave the host without embryonating and take 16 to 17 days, at 27°C to 34°C, to form the first juvenile stage (miracidium) and hatch (Neva, 1994). In experiments in India, miracidia were able to produce infection in the planorbid snail Helicorbis coenosus, which may be the natural intermediate host. Details of development in the snail are not known, but judging from the cycle of other members of the same family, they are presumed to form oocysts, one or two generations of rediae, and cercariae. Depending on the ambient temperature, the cercariae begin to emerge from the snails 28 to 152 days after infection. Like those of other species of Gastrodiscidae, the cercariae are thought to encyst on aquatic plants and develop into metacercariae. Geographic Distribution and Occurrence: This parasitosis occurs primarily in India (states of Assam, Bihar, Orissa, and West Bengal) and in Bangladesh, but has also been recorded in the Philippines, the Indochina peninsula, and in animals in Indonesia (Java), Malaysia, Myanmar, and Thailand. The geographic distribution may be wider, since the parasite was found in a wild boar in Kazakhstan. Human infection rates vary and can be very high, as in a village in Assam, India, where 41% of the population, mostly children, had the parasite’s eggs in their stools. The infection is also found in rodents and several species of nonhuman primates in Asia: rhesus monkeys (Macaca mulatta) and cynomologus monkeys (M. The infection rate in swine in India is higher in late summer and early autumn, reaching its peak between June and September (Roy and Tandon, 1992). The Disease in Man and Animals: The infection is clinically apparent probably only when the parasite burden is large. In these cases, there reportedly may be alter- ations of the mucosa of the colon and cecum, colitis, and mucoid diarrhea (Strickland, 1991). Source of Infection and Mode of Transmission: The natural definitive host appears to be swine, in which high rates of infection have been found. The definitive hosts acquire the infection through the digestive tract, perhaps by ingesting aquatic plants or untreated water containing metacercariae. Diagnosis: Diagnosis is based on detection of the presence of eggs in feces or, more easily, on identification of the trematode following administration of an anti- helminthic to the affected person. The eggs of Gastrodiscoides (150–170 µm by 60–70 µm) resemble those of Fasciolopsis buski,but are narrower and greenish. Control: Since the lifecycle of the parasite is not known, it is difficult to recom- mend control measures. Nonetheless, for individual protection it is suggested that people in endemic areas not consume aquatic plants or untreated water. For preven- tion through treatment of the animal reservoir, the best time is mid-summer, before the infection reaches its highest prevalence (Roy and Tandon, 1992). The life history of Gastrodiscoides hominis (Lewis and McConnel, 1876) Leiper, 1913—the amphistome parasite of man and pig. Seasonal prevalence of some zoonotic trematode infections in cattle and pigs in the north-east montane zone in India. Etiology: The agents of this infection are trematodes of the family Heterophyidae, which infect the intestine of man and other vertebrates. As of 1980, Malek (1980) had recognized 10 species in the world that were infective for man, the most common being Heterophyes heterophyes, Heterophyes nocens, Metagonimus yokogawai, and Stellantchasmus falcatus. In 1991, Chai and Lee (1991) added six more species that had infected man in the Republic of Korea: Centrocestus armatus, Heterophyes dispar, Heterophyopsis continua, M. For example, in a study carried out in Korea, 5 patients under treatment produced a total of 3,007 specimens of M. All the heterophyids have a similar biological cycle: the first intermediate host is an appropriate aquatic snail (Cerithidea, Cleopatra, Melania, Pironella, Semisulcospira, Tympanotomus), which ingests the mature eggs, and in which the cercariae are produced. In addition, there is a second intermediate host in which the metacercariae are produced—usually one of a large variety of fish that live in fresh or brackish water. When observed in host feces, the eggs contain a completely developed miracidium, which must be ingested by an appropriate aquatic snail (first intermediate host) in order to continue its development cycle. The cer- cariae invade the second intermediate host, which may be one of about a dozen species of fish from fresh or brackish water that customarily spawn in brackish or salt water. The cercariae form cysts under the scales or in the musculature of these fish and transform into metacercariae. In Egypt, metacercariae are found primarily in mullet (Mugil), Tilapia, and a few other species, and in Japan, in several species of goby belonging to the genus Acanthogobius. When man or another definitive host eats raw fish containing metacercariae, the parasites are released from the cystic envelope and develop inside the intestine until they turn into adult trematodes, which start to lay eggs in about nine days. The first intermediate hosts are snails of the genera Semisulcospira, Hua, or Thiara; the sec- ond intermediate hosts are fish belonging to the salmon and trout families. Most of the mullet contain metacercariae, with counts as high as 6,000 metacercariae per fish, and almost all the dogs and cats are infected. In addition to the endemic and hyperendemic areas already mentioned, a very low prevalence of H. However, subsequent surveys in other prefectures showed prevalence rates of less than 1% (Malek, 1980). In a hospital in Seoul, Korea, a total of 52,552 fecal samples were examined between 1984 and 1992, and the only heterophyid observed was M. The prevalence was higher in persons over 30 years old, but there was no correlation between age and intensity. In 1993, 465 persons and 68 fish were studied along the Hantan River in Korea and it was determined that 3. A large parasite burden can cause irritation of the intestinal mucosa with excessive secretion of mucus, superficial necrosis of the epithelium, chronic diarrhea, colic, and nausea. Aberrant eggs of the parasite sometimes enter the bloodstream and pro- duce granulomatous foci in various tissues and organs, including the myocardium and brain. In the Philippines, it is believed that 15% of the cases of fatal myocardi- tis may be caused by the eggs of these parasites (García and Bruckner, 1997). Other observations have included massive infiltrations of lymphocytes, plasmocytes, and eosinophils in the stroma, erosion of neighboring enterocytes, depletion of globet cells, and occasionally, edema of the villi (Chi et al. Its transmission would be similar to that of the canine rick- ettsia Neorickettsia helminthoeca via the trematode Nanophyetus salmincola (Soulsby, 1982). The custom of eating raw or undercooked fish is the main cause of the human infection. The parasite is less selective regarding the second intermediate host, which can be one of a number of fish species found in fresh, brackish, or salt water, and even certain shrimp. Contamination of the water with human or animal excreta ensures completion of the parasite’s development cycle. The primary definitive hosts vary depending on the parasite species: for some it is piscivorous birds; for others, dogs, cats, or man. Other definitive hosts include numerous species of birds and wild animals that feed on fish.

Many airlines will establish a fatigue risk management group where the airline physician may be one of the subject matter experts buy zestoretic with american express. The Medical Services can: • Provide regulator compliant policy and procedures and accredit providers for testing and intervention order zestoretic 17.5mg on line. Some activities that the Medical Services may be involved in include: • Development of Health and wellbeing strategies • Oversight of the airline health and wellbeing activities e buy zestoretic 17.5 mg on-line. Employees generally appreciate this activity and respond in a positive generic zestoretic 17.5 mg without prescription, co-operative way. Pamphlets, posters, colour films, video-cassettes, demonstrations on manikins, audio-visual presentations, and newsletters may all be helpful. The Medical Services can be very useful when it comes to advise on strategic health matters and the many liabilities that an airline may face. Insurance and Disability Some airlines have comprehensive insurance schemes for their employees which provide cover for health, illness, accident, death, or loss of licence. The airline Medical Services may be required to work in close conjunction with the insurers and insurance department of the airline, to provide accurate information and to ensure the claimant is both properly investigated and treated and also that the claim is justified. Informed consent to release of confidential medical information from the employee is essential. Some airlines will “self-insure” for some of these contingencies and the onus then falls especially on the Medical Services to ensure that a fair and reasonable balance is struck between employee claim and investigation and the corporate response. Claims should be properly investigated and reported on by the Medical Services in an impartial way to ensure that the employee is fairly treated. Occasionally, the employee or the employee’s union will attempt to steer the investigation or management of such a claim by suggesting or demanding use of experts specifically designated by them. That is not in the airline’s best interest, and the airline Medical Services should ensure that they seek, on behalf of the company the best, most independent and expert opinion available. Medico-Legal The airline Medical Services must be prepared to work closely with the legal department on claims of a medical nature against the company as well as any other legal matters requiring medical input. These claims may come from either passengers or employee, and the legal department will look to the Medical Services for expert medical advice and evidence. Customer Relations Customer enquiries and complaints may have a medical content or demand some medical explanation. This may range from complaints of “food poisoning on the flight” to allegations of injuries or illnesses caused during the flight. The types of complaint are extensive and the Medical Services is frequently called upon by the airline Customer Relations department to provide explanation or advice. Although management may request a medical assessment to ascertain a person’s fitness for a particular job, the ethics of the medical profession must be maintained. In general, the health professional may provide management with reports on fitness for work, appropriate limitations and likely duration. Medical information has no place in such a report and must not be included without written consent from the individual concerned. Where an employee consults an airline health professional because of personal problems or symptoms of a clinical nature, such a consultation must conform to the normal rules of medical confidentiality. There are circumstances which may be extremely sensitive but which may have serious implications in terms of safety of passengers or other employees. Such situations require considerable judgement on the part of the physician who must weigh the rights of the individual against the safety and rights of others. Factual evidence based medical information has to be provided in a concise manner. This may involve the Medical Services liaising with, and working with, other airline departments to collate the required information to pass back to the enquirer or complainant by Customer Relations. Aircraft accident Flying is acknowledged as the safest means of travel, but accidents can and do happen albeit rarely. The airline Medical Services must therefore work with other airline departments to produce an appropriate response to such a crisis. The development of a Crisis Response has to be global and encompass scenarios at locations, which may be very different to the hub from which the airline operates. There are a number of international organisations that make such expertise available to airlines and these are to be recommended. Their assistance at such times to provide logistical and medical manpower is invaluable as no Medical Services will have the resource to do this independently. It is important that accurate medical records, where possible, are kept of all aircrew as these may be required for assistance in identification after an accident. The way the airline and the Medical Services respond to such a crisis can significantly influence the future of the airline. Therefore very close co-operation between local and international medical and emergency organisations is essential and regular training and exercises involving mass casualty situations are essential. In most situations the Medical Services will not be directly involved at the accident scene, but will be expected to care for survivors after discharge from hospital, and for friends and relatives of passengers who arrive at the location in the aftermath. The Medical Services must also be prepared to participate in aviation medical committees and conferences. This allows discussion and exchange of information in a forum of peers and encourages best practice. Other international bodies such as the World Health Organisation are now also keenly interested in aviation and travel medical matters and seek the experience and knowledge of the airline Medical Services. Some also provide an employee dental health service with an extension to dependants or families as well. The level of primary health care provision is influenced by the local facilities and culture. While there is also a fairly large body of literature on in-flight incidents, those incidents are considered as exceptions and should be addressed separately. This approach does not suggest that those incidents should be neglected; however, each incident is different and should be investigated appropriately. When a common problem is identified in a particular type of aircraft, the same rationale applies. It is useful to remember that three different groups share the aircraft environment: the pilots who are healthy and perform sedentary but safety sensitive work, the cabin crew who are healthy and perform fairly intensive physical activities, and the passengers who are sedentary but who can be in any state of health or ill health. Contrary to popular belief, the aircraft cabin is not pressurised to ground level equivalent. For mechanical and economic reasons, it is practically impossible to maintain ground equivalent pressure at high cruising altitudes. The pressurisation schedule was developed to vary between ground level pressure and a maximum equivalent cabin altitude of 2400 meters (8000 feet) depending on the aircraft altitude. Currently most aircraft are pressurised by bleeding air from its engines before the combustion chamber. The pressurisation system draws air from different stages of the compressor, before it enters the combustion chamber, and redirects it to the aircraft cabin. With the assistance of an outflow valve, the pressure is raised and maintained to a predetermined desired level. However, it is possible to have a mechanical malfunction which might allow contaminants into the cabin. This would constitute an incident, as described above, and the mechanical malfunction should be rectified immediately. Returning to the pressurisation schedule, it is worth noting that this approach was accepted many decades ago when all the flights were relatively short, the aircrew were all relatively young and virtually no sick passengers travelled. In other words, the rationale was based on an average healthy young person, whether this person was a passenger or an aircrew member. Demographic and flight profiles have changed significantly over the years, and the current question is whether the original rationale is still valid. The selection of 2400 meters (8000 feet) was based on the oxyhemoglobin dissociation curve which shows that up to that level the hemoglobin oxygen saturation normally remains above ninety percent in the average healthy individual. The reduced oxygen partial pressure creates a mild hypoxia that is well tolerated by healthy individuals. As several body cavities contain gas, these cavities will be affected; the gas expansion will mainly affect the middle ear, the sinuses and the bowels. It also explains why a passenger with an active pneumothorax could not be accepted for air travel in a commercial aircraft. The reduced total pressure could also have an impact on evolved gas, hence the restrictions for flying after diving. There are two main types of ventilation system: one provides one hundred percent fresh air at all times. As the air coming out of the engine is extremely hot, it is passed through an air conditioning unit before it enters the cabin.

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