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Asymptomatic or subclinical infection with seroconversion is frequent gastritis symptoms temperature order bentyl mastercard, espe cially in settings of endemic infection gastritis diet 8 month generic bentyl 20 mg on-line. The reservoirs for Leptospira species include a wide range of wild and domestic animals gastritis and chest pain buy cheap bentyl on-line, primarily rats gastritis duration of symptoms bentyl 20mg on-line, dogs gastritis from not eating buy bentyl uk, and livestock (cattle chronic gastritis definition purchase line bentyl, pigs) that may shed organisms asymptomatically for years. Leptospira organisms excreted in animal urine may remain viable in moist soil or water for weeks to months in warm climates. Humans usu ally become infected via entry of leptospires through contact of mucosal surfaces (espe cially conjunctivae) or abraded skin with contaminated environmental sources. Populations in regions of high endemicity in the tropics likely encounter Leptospira organisms commonly during routine activities of daily living. People who are predisposed by occupation include abattoir and sewer workers, miners, veterinar ians, farmers, and military personnel. Common history includes being submerged in or swallowing water during such activities. For these reasons, serum specimens always should be obtained to facilitate diagnosis. Further, in populations with high endemicity, background reactivity requires establishing regionally relevant diagnostic criteria and establishment of diagnostic versus background titers. Antibody increases can be transient, delayed, or absent in some patients, which may be related to antibiotic use, bacterial virulence, immunogenetics of the individual, or other unknown factors. Microscopic agglutination, the gold standard serologic test, is per formed only in reference laboratories and requires seroconversion demonstrated between acute and convalescent specimens obtained at least 10 days apart. For patients with mild disease, oral doxycycline has been shown to shorten the course of illness and decrease occurrence of leptospiruria; ampicillin or amoxicillin can also be used to treat mild disease. However, immunization may not prevent the shedding of leptospires in their urine, thus contaminating environments with which humans may come in contact. Indications for prophylactic doxycycline use for children have not been established. Fetal infection results from transplacental transmission following maternal bacteremia. Approximately 65% of pregnant women with Listeria infection experience a prodromal illness before the diagnosis of listeriosis in their newborn infant. Late onset infection may result from acquisition of the organism during passage through the birth canal or, rarely, from environmental sources. Clinical features characteristic of invasive listeriosis outside the neonatal period or pregnancy are bacteremia and meningitis with or without parenchymal brain involve ment, and less commonly brain abscess or endocarditis. L monocytogenes also can cause rhombencephalitis (brain stem encephalitis) in otherwise healthy adolescents and young adults. Outbreaks of febrile gastroenteritis caused by food contaminated with a very large inoculum of L monocytogenes have been reported. The prevalence of stool carriage of L monocytogenes among healthy, asymptomatic adults is estimated to be 1% to 5%. The saprophytic organism is distributed widely in the environment and is an important cause of illness in ruminants. Commonly incriminated 1 foods include deli-style, ready-to-eat meats, particularly poultry; unpasteurized milk, and soft cheeses, including Mexican-style cheese. The last large outbreak in the United States occurred in 2011, resulting in 143 hospitalizations, and was linked to con taminated cantaloupe. Combination therapy using ampicillin and a second agent is recommended for severe infections, including meningitis, encephalitis, endocarditis, and infections in neonates and immunocompromised patients. Therapy with intrave nous ampicillin and an aminoglycoside, usually gentamicin, has been used traditionally. Use of an alternative second agent that is active intracellularly (eg, trimethoprim sulfamethoxazole, quinolones, linezolid, or rifampin) is supported by clinical reports in adults. Longer courses are necessary for patients with endocarditis or parenchymal brain infection (cerebritis, rhombencephalitis, brain abscess). Diagnostic imaging of the brain near the end of the anticipated duration of therapy 1American Academy of Pediatrics, Committee on Infectious Diseases and Committee on Nutrition. Consumption of raw or unpasteurized milk and milk products by pregnant women and children. Recommendations for Preventing Foodborne Listeriosis General recommendations Washing and handling food Rinse raw produce thoroughly under running tap water before eating, cutting, or cooking. Cook meat and poultry thoroughly Thoroughly cook raw food from animal sources, such as beef, pork, or poultry to a safe internal temperature. Recommendations for Preventing Foodborne Listeriosis, continued Cheeses Do not eat soft cheese such as feta, queso blanco, queso fresco, brie, Camembert, blue-veined, or panela (queso panela) unless it is labeled as made with pasteurized milk. Seafood Do not eat refrigerated smoked seafood, unless it is contained in a cooked dish, such as a cas serole, or unless it is a canned or shelf-stable product. Clinical isolates should be forwarded to a public health laboratory for molecular subtyping. Early localized disease is characterized by a distinctive lesion, erythema migrans, at the site of a recent tick bite. Erythema migrans is by far the most common manifestation of Lyme disease in children. Erythema migrans begins as a red macule or papule that usually expands over days to weeks to form a large, annular, erythematous lesion that typically increases in size to 5 cm or more in diameter, sometimes with partial central clearing. Factors that distinguish erythema migrans from local aller gic reaction to a tick bite include larger size (>5 cm), gradual expansion, lack of pruritus, and slower onset. Constitutional symptoms, such as malaise, headache, mild neck stiff ness, myalgia, and arthralgia, often accompany the rash of early localized disease. In early disseminated disease, multiple erythema migrans lesions may appear several weeks after an infective tick bite and consist of secondary annular, erythematous lesions similar to but usually smaller than the primary lesion. Ophthalmic conditions (conjunctivitis, optic neu ritis, keratitis, uveitis) can occur, usually in concert with other neurologic manifestations. Systemic symptoms, such as low-grade fever, arthralgia, myalgia, headache, and fatigue, also are common during the early disseminated stage. Occasionally, people with early Lyme disease have concurrent human gran ulocytic anaplasmosis or babesiosis, which are transmitted by the same tick. Coinfection may present as more severe disease than Lyme monoinfection, and the presence of a high fever with Lyme disease or inadequate response to treatment should raise suspicion of concurrent anaplasmosis or babesiosis. Certain laboratory abnormalities, such as leukope nia, thrombocytopenia, anemia, or abnormal hepatic transaminase concentrations, raise concern for coinfection. Late disease occurs in patients who are not treated at an earlier stage of illness and most commonly manifests as Lyme arthritis in children. Arthritis can occur without a history of earlier stages of illness (including erythema migrans). Polyneuropathy, encephalopa thy, and encephalitis are extremely rare manifestations of late disease. Children who are treated with antimicrobial agents in the early stage of disease almost never develop late disease. No causal relationship between maternal Lyme disease and abnormalities of pregnancy or con genital disease caused by Borrelia burgdorferi has been documented. In none of these situations is there credible evidence that persistent infection with B burgdorferi is demonstrable, let alone causal. In Southern states, I scapularis ticks are rare compared with the northeast; those ticks that are present do not commonly feed on competent reservoir mammals and are less likely to bite humans because of different questing habits. Reported cases from states without known enzootic risks may have been acquired in states with endemic infection or may be misdiagnoses resulting from false-positive serologic test results or results that are misinterpreted as positive. The incubation period from tick bite to appearance of single or multiple erythema migrans lesions ranges from 1 to 32 days, with a median of 11 days. Clinical manifestations of infection vary some what from manifestations seen in the United States. These differences are attributable to the different genospecies of Borrelia responsible for European Lyme disease. Early localized Lyme disease is diagnosed clinically on recognition of an erythema migrans lesion. Although erythema migrans is not strictly pathognomonic for Lyme dis ease, it is highly distinctive and characteristic. In areas endemic for Lyme disease during the warm months of the year, it is expected that the vast majority of erythema migrans is attributable to B burgdorferi infec tion, and early initiation of treatment is appropriate. Diagnostic testing is based on serology; during early infection, the sensitivity is low. Thus, diagnostic testing is not recommended for this stage of illness; only approximately one third of patients with solitary erythema migrans lesions are seropositive. Patients who have multiple lesions of erythema migrans also are diagnosed clinically, although the like lihood of seropositivity is higher in this situation. There is a broad differential diagnosis for all disseminated manifestations of Lyme disease. Thus, the diagnosis of disseminated Lyme disease requires a typical clinical illness, plausible geographic exposure, and a posi tive serologic test result. The initial test is a quantitative screening for antibodies to a whole-cell sonicate or C6 antigen of B burgdorferi. This is the most foolproof way of ordering the appropriate 2-tier test for Lyme disease. Thus, it is imperative that the physician review the interpretive criteria for the test overall rather than risking overinterpretation of what may be a nega tive test result. Almost all positive serologic test results in these patients are false-positive results. Development of antibodies in patients treated for early Lyme disease does not indicate lack of cure or presence of persistent infection. Consequently, tests for antibodies should not be repeated or used to assess the success of treatment. Although these tests are commercially available from some clinical laboratories, they are not appropriate diagnostic tests for Lyme disease. Treatment of erythema migrans almost always prevents development of later stages of Lyme disease. Erythema migrans usually resolves within several days of initiating treat ment, although constitutional symptoms may take months to resolve. Oral antibiotics are appropriate and effective for most manifestations of disseminated Lyme disease, including multiple erythema migrans and some cases of Lyme carditis treated as outpatients. For patients requiring hospitalization for Lyme carditis (eg, high grade atrioventricular block), initial therapy usually is parenteral but can be completed with oral therapy. Doxycycline is appropriate for treatment of facial nerve palsy without clinical manifes tations of meningitis; lumbar puncture is not indicated. However, Lyme-associated neu ropathies affect peripheral nerves, and it is possible that these complications do not require therapy that crosses the blood-brain barrier. European studies provide some evidence that oral doxycycline is effective for Lyme meningitis; this must be interpreted in the different genetic context of European borreliosis. Nonetheless, for a patient with Lyme meningitis and a prohibitive allergy to cephalosporins, doxycycline may be an attractive alternative to cephalosporin desensitization. Neurologic disease typically is treated for 14 days, with select cases receiving up to 21 days of therapy. Arthroscopic synovectomy may be required rarely for more disabling or refractory cases. However, it is not clear that similar symptoms occur any more frequently in patients with a history of Lyme disease than in the population at large. Administration of additional antibiotics to a patient following standard treatment for Lyme disease is strongly discouraged except when there is objective clinical evidence of reinfection, which can occur occasionally in areas of high endemicity. Patients with Lyme disease may be simultaneously infected with Babesia microti (babesiosis), Anaplasma phagocytophilum (human granulocytic anaplasmosis), or both. These diagnoses should be suspected in patients with early Lyme disease who have high fevers, hematologic abnormalities, or elevated hepatic transaminase concentrations. Additionally, patients who contract Lyme disease in Europe may be coinfected with tickborne encepha litis virus. Powassan virus and Ehrlichia muris-like agent also are transmitted by blacklegged ticks, but coinfections have not been described to date. There are no data to support antibiotic prophylaxis of other tickborne illnesses, such as anaplasmosis, ehrlichiosis, babesiosis, or Rocky Mountain spotted fever. To date, no documented cases of B burgdorferi transmission have occurred as a result of spirochete transmission via blood transfusion. Nevertheless, because spi rochetemia occurs in early Lyme disease, patients with active disease should not donate blood. Patients who have been treated for Lyme disease can be considered for blood donation. Recurrent secondary bacterial infections hasten progression of lymphedema to the more severe form known as elephantiasis. B timori is restricted to certain islands at the eastern end of the Indonesian archipelago. Complex decongestive physiotherapy may be effective for treating lymphedema and requires strict attention to hygiene in the affected anatomical areas. Chyluria originating in the bladder responds to fulguration; chyluria originating in the kidney usually cannot be corrected. Symptomatic infection may result in a mild to severe illness, which includes fever, malaise, myalgia, retro-orbital headache, photophobia, anorexia, and nausea. A biphasic febrile course is com mon; after a few days without symptoms, the second phase may occur in up to half of symptomatic patients, consisting of neurologic manifestations that vary from aseptic meningitis to severe encephalitis. Arthralgia or arthritis, respiratory tract symptoms, orchitis, and leukopenia develop occa sionally. Congenital murine infection is common and results in a normal-appearing litter with chronic viremia and particularly high virus excretion.

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The Update 2014 committee was concerned about the strong degree of mis classifcation associated with publications concerning various health outcomes au thored by researchers who categorized exposure based on a variable in a patients electronic medical record indicating whether the individual was exposed to Agent Orange (Ansbaugh et al gastritis korean order bentyl toronto. Only a few herbicidal chemicals were used as defoliants during the Vietnam confict: esters and salts of 2 gastritis diet 600 order bentyl with a mastercard,4-D and 2 gastritis diet ãîðîñêîï buy bentyl from india,4 gastritis symptoms lower abdominal pain purchase discount bentyl on line,5-T gastritis erosive symptoms best purchase bentyl, cacodylic acid gastritis symptoms vs gallbladder bentyl 20mg online, and picloram in various formulations. Among the various chemical classes of herbicides that have been identifed in published studies reviewed by the committee, phenoxy herbicides, particu larly 2,4-D and 2,4,5-T, are directly relevant to the exposures experienced by U. Many scientifc studies reviewed by the current and prior committees re port exposures to broad categories of chemicals rather than to those specifc chemicals. M any studies have examined the relationship between exposure to pesticides and adverse health outcomes, while others have used the category of herbicides without identifying specifc chemicals. Chapter 3, Evaluation of the Evidence Base, contains a detailed discussion of inclusion and exclusion criteria for the studies reviewed in the current update. Forest Service that predicts agricultural pesticide ground concentrations based on variables related to dispersal, drift, and deposition. A team of researchers in Colum bia Universitys M ailman School of Public Health was awarded the contract for the Characterizing Exposure of Veterans to Agent Orange and Other Herbicides in Vietnam project. Several sources of information concerning spraying activi ties and information on the locations of military units assigned to Vietnam were integrated into a database. M obility factor analysis, a technique used for studying troop movement, was developed for use in reconstructing herbicide-exposure histories. The analysis is a three-part classifcation system for characterizing the location and movement of military units in Vietnam. It comprises a mobility designation (stable or mobile), a distance designation (usually in kilometers) to indicate how far a unit might travel in a day, and a notation of the modes of travel avail able to the unit (by air, by water, or on the ground by truck, tank, or armored personnel carrier). A summary of the fndings on the extent and pattern of herbicide spraying (Stellman et al. In those publications the researchers argued that it is feasible to conduct epidemio logic investigations of veterans who served as ground troops during the Vietnam W ar. The report concluded that despite the short comings of the exposure assessment model in its current form and the inherent limitations in the approach, the committee agreed that the model holds prom ise for supporting informative epidemiologic studies of herbicides and health among Vietnam veterans and that it should be used to conduct studies (p. This model has since been used in analyses of the Korean Veterans Health Study (Yi and Ohrr, 2014; Yi et al. They suggested that dermal exposure through both direct deposition and post-application transfer from foliage could be derived from application information such as aircraft speed and altitude, from nozzle characteristics, and from droplet evaporation and environmental parameters such as canopy density, canopy roughness, and crosswind speed. The authors did not consider exposures resulting from contact with soil and dust or through inhala tion because they considered these routes to be negligible (Ginevan et al. However, subsequent reviews of the methodology underlying the authors analyses (S. Stellman, 2014, 2015) found several weaknesses that call the results by Ginevan et al. The requisite information is still not available despite concerted efforts to use modeling to re construct likely exposure from records of troop movements and spraying missions (J. Prior committees have thought it unlikely that additional information or more sophisticated methods would permit any sort of quantitative assessment of Vietnam veterans increased risks of particular adverse health outcomes that are attributable to exposure to the chemicals associated with herbicide spraying in Vietnam. Accordingly, the lack of exposure estimations for Vietnam veterans will likely remain a hurdle to epidemiologic studies, and unless this issue is resolved, the potential for additional epidemiologic studies to yield improved information regarding the specifc question of whether an associa tion exists between herbicide exposure and health outcomes will remain limited. Veterans and Agent Orange: Update 11 (2018) 3 Evaluation of the Evidence Base this chapter describes the approach and methods that the committee used to identify and evaluate the scientifc and medical literature on exposures to herbi cides that occurred in U. The committees process entailed the following steps: a literature search, screening of abstracts, a full text review of studies fagged in the abstract screening, and the evaluation of a fnal set of stud ies identifed as relevant after the full text review. The frst part of this chapter details the methodology used to identify and screen the literature. The second part of the chapter details the evaluation criteria used to review the relevant studies, including the types of studies considered, the health outcomes considered, and the categories of association used to draw conclusions about the strength of the evi dence of possible health effects resulting from herbicide exposure. The committee also describes some of the issues it encountered when reviewing the literature on Vietnam War exposures and health outcomes, such as multiple exposures and in dividual variability. To begin, the committee oversaw extensive searches of the scientifc literature using a strategy adapted from prior committees literature search methodology (see Box 3-1). This committees search included additional terms to evaluate specifc conditions called out in the Statement of Task: possible generational health effects, myelo proliferative neoplasms, and brain cancer, in particular, glioblastoma multiforme (see Chapter 1 for the full Statement of Task). For this update, electronic searches of the medical and scientifc literature were carried out on four databases: Web of Science, Scopus, Medline, and Em base. The four searchable databases index biological, chemical, medical, and toxicological publications. The full texts of the articles were searched so that if any of the search terms was included in the title or abstract or indexed in the key words or text of the article (excluding the cited references section), the article would be included in the results of the search. Using the search terms in Box 3-1, the databases were searched in two phases, with the searches spanning over timeframes that were extended from those used in prior updates. In the spring of 2017, the databases were searched for articles published between January 1, 2014, and March 31, 2017. Then in early February 2018 the databases were again searched for any articles with the relevant search terms published between March 1, 2017, and December 31, 2017. Other than dates, no limitations (such as language, populations, or species) were put on the search. In addition, potentially relevant articles were also identifed by searching the reference lists of relevant review and research articles, books, and reports. Exact duplicate articles and those that had been summarized and referenced in Update 2014 were deleted. The committee became aware of a few studies that reported updated fndings on relevant exposed populations (such as the Seveso, Italy, cohort and New Zealand phenoxy herbicide producers) published following the December 31, 2017, search cutoff and reviewed these studies as well. The frst search produced in excess of 12,000 hits, and the second search identifed more than 1,600 articles of potential relevance. Article titles and abstracts were screened for relevance by committee members and the Health and Medicine Division staff to determine which studies should be considered for full-text retrieval using the criteria in Box 3-2. The current committee expands upon that perspective by placing it in a framework that underscores the relevance of the concepts of multifactorial causa tion, the literature on which has recently begun to mature and offer new insights. The statistical interactions of risk factors, which can have synergist or antagonistic effects, can result in ef fects of combined exposures that would not have been predicted based on their independent impacts. An example of a synergistic interaction is the association with lung cancer from combined exposures to workplace arsenic and smoking: in this case, the risks from arsenic are much higher among smokers than among non-smokers (Hertz-Picciotto et al. Disentangling the separate effects of combined exposures or risk factors in relation to a particular outcome does raise serious challenges, however, and it may indeed be infeasible when the correlations among those exposures are ex ceedingly high, to the point of inseparability, or when suffciently large studies cannot be conducted. Exam ples include exposure to herbicides containing organophosphates (not otherwise specified), atrazine, paraquat, glyphosate, m etam ifop, rotenone, clarityon, and diuron; and exposure to pesticides and insecticides. Inorganic ar senic and benzene were not considered as relevant service-related exposures among Vietnam veterans and were not evaluated in relation to their potential risk of adverse health outcomes. Thus, a nuanced and comprehensive approach to combined exposures is critical to understanding causation. Underlying susceptibility is not always ge netic, but can instead be a prior or concomitant exposure, and thus the possibility of multifactorial causation requires paying attention to confounding as well as to interactions. Very few epidemiologic studies on exposure toV picloram or cacodylic acid have been published, which is another reason for the committee to consider metabolites of these compounds. However, the biologi cally active compound benzene does not emerge from dioxin, whose three-ring structure is extremely stable and resistant to metabolism. The combinations of the chemicals with other agents that might lead to problems are virtually infnite, and hence, not feasible for systematic and comprehensive evaluation. Real-life experience, as investigated with epidemiologic studies, effectively integrates any results of exposure to a target substance in combination with other substances that may be etiologically relevant. As explained, inorganic arsenic and benzene were not considered as relevant service-related exposures among Vietnam veterans and thus were not evaluated in terms of their risk for adverse health outcomes. All studies that discussed health effects or changes in pathophysiology or cell sig naling were considered if the text indicated that any of the herbicides of interest (or any of their components) may have been investigated. The committee only included literature that had undergone peer review or government reports and invited presentations that were provided to the committee, under the assumption that they have been carefully reviewed. The process of peer review by fellow professionals increases the likelihood that high-quality studies will appear in the literature, but it does not guarantee the validity of any particular study or the ability to generalize its fndings. An exception to this practice was made for studies that indicated exposure to herbicides but did not characterize exposure with suffcient specifcity for their results to meet the committees criteria for inclusion in the evidentiary database. For example, numerous case-control studies characterized exposure to pesticides or herbicides on the basis of job titles, farm residence, or longest-worked industry. For instance, this rubric would apply to any published articles from the Agricultural Health Study because 2,4-D was one of the most frequently used pesticides in this large prospective cohort, but some results have lumped all herbicide exposure together. Studies with original data collection and analyses were preferred over stud ies that were re-analyses of a population (without the incorporation of additional information), pooled analyses or meta-analyses, reviews, and so on, and the former are the type of evidence that the committee preferentially considered when assessing the strength of association between herbicide exposure and a health outcome when drawing its conclusions. W hile studies of the latter type may be informative and may be discussed in conjunction with primary results or in synthesis sections on a given health outcome, they are not themselves part of the evidence dataset and therefore were not considered in the fnal count of new literature considered in this volume. The quantitative and qualitative procedures underlying the committees literature evaluation have been made as explicit as possible, but ultimately the conclusions about associations expressed in this report are based on the committees collective judgment. The committee has endeavored to express its judgments as clearly and precisely as the data allow. Full text was then obtained for any articles that were considered potentially rel evant based on their titles and abstracts and after applying the inclusion and ex clusion criteria. Full-text articles were distributed among the committee members based on their areas of expertise, with at least two committee members reviewing each paper. Because of the variability in the descriptions and diagnoses of the health conditions considered in this report, the committee made no a priori assumptions about the usefulness of any article or report for a health outcome. Each study was reviewed and objectively evaluated for each health outcome it presented. If a study examined more than one health outcome, it was considered separately for each of those outcomes. After reading, if the full text revealed that the study met one of the exclusion criteria (see Box 3-2), it was excluded from further consideration. After review of the full text of the identifed articles, studies that were con sidered relevant (165 epidemiologic studies and nearly 100 toxicologic studies) were discussed and evaluated thoroughly, and are included in this report. Based on the details of exposure and the description of how exposure was measured, an epidemiologic study was classifed either as a primary article, in which case it was given full evidentiary weight, or as a second ary article, in which case it was reviewed and more briefy described under the heading of Other Identifed Studies. An epidemiologic study was also clas sifed as secondary if the outcome was a biologic marker of effect as opposed to a recognized condition or disease. Mechanistic and toxicologic studies contributed to the evidence for biologic plausibility but were not considered primary studies, so that based on those studies alone, their weight would not be enough to change the level of evidence of an association. The toxicologists on the committee provided a summary of previous and new mecha nistic or toxicologic studies for that health outcome. When drafting language for a conclusion, the committee considered the nature of the exposures, the nature of the specifc health outcome, the populations exposed, and the quality of the evidence examined. The draft text was reviewed and discussed in further plenary sessions until all committee members reached a consensus on the description of the studies and the conclusion for each health outcome. The committee did not use a formulaic approach to determining the number of primary or supporting studies that would be necessary to assign a specifc category of association. Rather the committees review required a thoughtful and nuanced consideration of all the studies as well as expert judgment, and this could not be accomplished by adherence to a nar rowly prescribed formula of what data would be required for each category of association or for a particular health outcome. If no new primary studies for a health outcome were identifed, the evidence table from Update 2014 was included. Effect estimates, data, and units of measure are presented as reported in the cited studies, except where otherwise noted. The committee did not collect original data, nor did it perform any secondary data analyses, such as meta-analyses. Epidemiologic studies effectively integrate any results of exposure to a target substance in combination with other substances that may be etiologically relevant. Several types of epidemiologic studies were evaluated, including cohort, case-control, and cross-sectional designs. The committee weighed the importance of the epidemiologic studies in the following order: Vietnam veterans, occupationally exposed workers, and people who were exposed environmentally. Including these more highly exposed populations had the additional advantage that epidemiologic studies of them were likely to have greater statistical power to detect any adverse effects that might occur with exposure. Toxicologic studies, particularly in animal models, are included to inform the understanding of biologic plausibility through the toxicology of the chemicals and their exposure pathways. Instead, having served in Vietnam or participating in the Agent Orange Registry is often considered a proxy of her bicide exposure. Therefore, it is diffcult to quantify the risk of specifc health outcomes when the exposures of the total at-risk population have not been mea sured or estimated. In the absence of actual measures of exposure, comparisons between deployed and non-deployed Vietnam-era veterans are considered the next most relevant comparison. Moreover, in many studies of Vietnam veterans, not all health outcomes of interest were reported (in some cases there were too few cases to report, only specifc health outcomes were of interest, or the veteran population was too young for a particular manifestation). Some occupational and environmental cohorts that received exceptionally high exposures have produced many informative results and provide stronger evidence about health outcomes than studies of Vietnam veterans because the exposures were better characterized and measured sooner relative to the exposure. Moreover, in several studies of chemical-production plant workers, the magnitude and duration of exposure to the chemicals were measured and generally greater than among Vietnam veterans, so the likelihood that any possible health consequences would be manifested was greater. Other populations, such as the Agricultural Health Study, a prospective cohort study of U. For each health outcome, occupational and environmental studies are presented after the studies of Vietnam veterans. Animal and Mechanistic Studiesthe committee used studies of toxicology data to determine whether there is a plausible biologic mechanism or other evidence of a causal relationship between herbicide exposure and a health effect. A positive statistical association between an exposure and an outcome does not necessarily mean that the exposure is the cause of that outcome.

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Retail pharmacists may Donors and international organizations can also sup 4 / National medicine policy 4 gastritis diet öèòàòû order bentyl cheap online. Has it been ers and senior management ofcers in the ministry updated in the past ten years Ethical Infrastructure for Good Governance in the Public United Kingdom in 1968 xango gastritis 20mg bentyl overnight delivery, Bangladesh in 1982 gastritis diet ìàøà bentyl 20mg generic, the Pharmaceutical Sector gastritis nursing diagnosis cheap bentyl online american express. Geneva: World Health Organization/Department of Medicines Philippines in 1986 gastritis kidney pain bentyl 20 mg free shipping, Guinea in 1992 gastritis natural cures order bentyl with amex, and Uganda in Policy and Standards. Indicators for countries show that success in terms of public health is Monitoring National Drug Policies: A Practical Manual. Is Access to Essential Medicines as Part of the Fulflment of the selectionmedicines/committees/expert/17/sixteenthadultlist Right to Health Enforceable through the Courts How to Develop and Implement a National Drug Pharmaceuticals in Two Provinces in South Africa. Lack as the source of their primary health care but also as part of regulations on quality standards and evaluation for of their spiritual and cultural belief systems. Meanwhile, people in Europe, Australia, Traditional medicine is a comprehensive term that refers and North America have increasingly embraced alternative to forms of medicine long-established in a country, whether and complementary practices, such as the use of herbal developed or developing. Health care practices that are medications, to supplement their standard health care. Herbal medicines include herbs, Definitions of traditional and complementary herbal materials, herbal preparations, and fnished herbal medicine products that contain therapeutically active ingredients that are plant based. Traditional and complementary medicine usage is wide Traditional medicine has been used continuously in devel spread. They also include total of the knowledge, skills, and practices based on the preparations made by steeping or heating herbal theories, beliefs, and experiences indigenous to diferent materials in alcoholic beverages and/or honey, or in cultures, whether explicable or not, used in the mainte other materials. The terms com mixture herbal products may contain excipients in plementary medicine and alternative medicine are used addition to the active ingredients. However, fnished interchangeably with traditional medicine in some coun products or mixture products to which chemically tries. They refer to a broad set of health care practices that defned active substances have been added, includ are not part of that countrys own tradition and are not ing synthetic compounds and/or isolated constitu integrated into the dominant health care system. This refers to the other human health benefts, which contain either raw or long historical use of these medicines. In some established and widely acknowledged to be safe and traditions, material of inorganic or animal origin may efective, and may be accepted by national authorities. Tese are ingredients of herbal fresh juices, gums, fxed oils, essential oils, resins, medicines with therapeutic activity. In some countries, these where the active ingredients have been identifed, the materials may be processed by various local proce preparation of these medicines should be standardized dures, such as steaming, roasting, or stir-baking with to contain a defned amount of the active ingredients, if honey, alcoholic beverages, or other materials. Typically, both traditional and elsewhere (the brain drain phenomenon); sub-Saharan conventional practitioners are unaware or even suspicious of Africa has been particularly hard hit (see Chapter 51). As a result, alternative therapies are appeal those patients taking certain herbal medications in combi ing because they are perceived as more natural and therefore nation with pharmaceuticals. A perceptual diference between cultures appear to be weakening in some areas, such as government may be that people in developing countries are more likely recognition. Traditional medicine therapies are commonly used in Perceived safety developing countries because they are ofen more widely available and more afordable than conventional therapies. Although consumers may perceive herbal products as natural and therefore less likely to cause Poor quality problems, these products are not without risk and are not necessarily safer than conventional pharmaceuticals. For treatment of chronic, debilitating diseases that defy con example, an analysis of diferent red yeast rice products on ventional pharmaceuticals. Indeed, plant extracts have been the market showed levels varying by 100-fold across ten proved to have pharmacological efects on many condi products, and four were contaminated with a mycotoxin tions, both acute and chronic. In 2009, a as plants (Newman and Cragg 2007); for example, aspirin manufacturer recalled its herbal weight-loss product, which (salicylic acid) uses a compound derived from the white was found to actually contain the unlabeled prescription willow tree, and paclitaxel, a chemotherapy agent, is made drug sibutramine, which can substantially increase blood using a substance found in the Pacifc yew tree. However, traditional healers have been with serious cases of liver damage (Stevinson et al. Many people believe that, because herbal medications are natural, or have been used in some parts of the world for Lack of information generations, they must be safe. But, like modern pharmaceu ticals, herbal medications can cause adverse efects (Farah et Many consumers in both developed and developing coun al. Most countries themselves, however, may be uninformed about poten have no adverse drug reaction surveillance (pharmacovigi tial adverse efects and the safe use of herbal medicines. Although members, traditional healers, and conventional health collaboration between conventional and traditional practitioners. Conventional screening methods are used to could be trained as efective counselors on sexually trans determine the problem before treatment begins. The doctors were so mation, the center has published booklets, training kits, impressed that they initiated collaboration with healers educational videos, and a newsletter. They not only treat peoples opportunistic infec with conventional health practitioners to promote col tions, but also encourage patients behavioral changes laboration between traditional healers and health care and advise them on good nutrition and healthy living. The project is working to improve two-way communica I work together with fellow healers to educate the tion and referral between sangomas and conventional communities. The project is working with all parties to clarify patient confdentiality In South Africa, an estimated 80 percent of people regu issues, which should help improve communication and larly see sangomas, or traditional healers. Record keeping is seen as an Council (including the Ethekwini Traditional Healers important element of successful collaboration between Council), as well as two other traditional healers orga the traditional and conventional health systems. In medicines and conventional medicines (Ernst 2001; a fatal example, the label on a bottle of Chinese wintergreen Fugh-Berman 2000). An elderly consumer seeking health care providers and, in the case of self-treatment, relief from arthritis drank the entire contents of the 60 mL better consumer information. This of minimal health care packages; and in Europe, licensing overarching strategy includes four major objectives: (1) providers and creating standards of training and priorities framing government policy; (2) ensuring safety, efcacy, for research have become crucial issues. Fify-one additional countries, For example, the government of India ofcially recognized however, reported having such policies in development. More than government oversight and without patient or consumer 700,000 registered traditional medical practitioners are protection. Terefore, national policies should encompass active in India and almost 500 colleges of Ayurvedic and legislation and regulation of practice and products; educa other traditional medicine education exist (Joshi 2008). Worldwide, only China, the time, such a policy is not useful if it unduly hinders patient Democratic Peoples Republic of Korea, the Republic of treatment options or leads to higher health care costs. But, again, because national priorities difer, government approaches to legislation and regulations Many developing countries have a weak regulatory infra lack consistency (see Country Study 5-2). In the United Kingdom, only the prac have little incentive to invest in research. Few national credentialing and latory standards should work toward setting up a national licensing bodies are available to determine qualifcations for system. In some countries, such as Norway, Zimbabwe, and ernment authorities and researchers. The following table summarizes the status of regulations, training, and insurance coverage in eight countries as of 2005 or before. Unlicensed herbal products are not curriculum of medical schools and making required to meet any specific quality or safety standards, but that accredited postgraduate training available. Promotion of these objectives is a shared responsibility of the Ministry of Health, Vietnamese Traditional Medicine Association, and the Viet Nam General Union of Medicine and Pharmacy. Examples are found in China, Germany, Ghana, India, Without any sort of manufacturing standard, herbal Indonesia, Mali, Nigeria, Norway, Tailand, the United products range in composition from products that are vir States, and Vietnam. Given their natural complexity and the critical step in ensuring the quality of herbal medicine. Overall, the general lack of regulations chromatography and qualitative and quantitative high governing quality-control standards and consistency among performance liquid chromatography methods are being herbal products hinders the ability of health professionals to used to confrm the identity and quality of raw materials. Tese guide vent residue that may be the cause of an adverse reaction, lines not only facilitate the technical work of drug regulatory rather than the plant. Similarly, simultaneous conventional authorities but also encourage countries to establish quality pharmaceutical and illicit drug use should be documented control procedures for herbal medicines. Chapter 35 provides more information on developed within diferent cultural and regional contexts, pharmacovigilance monitoring. Importantly, scientifc Poor countries are the most in need of inexpensive, efective research has increased on the chemistry and pharmacol treatments for diseases and access to essential medicines. Pharmacovigilance needs to for self-regulation and contribute to enhanced profes incorporate instruments to identify adverse reactions expe sional standards and increased consumer trust and safety. For example, an adverse reac tional health sectors, partly through links in their educa tion recorded for a product labeled ginseng could be tional systems (Holliday 2003). Johns wort Mild depression More effective than placebo, as effective as (and safer than) synthetic antidepressants Kava kava Anxiety More effective than placebo Saw palmetto Prostate hyperplasia Effective in relief of symptoms Horse chestnut(Aesculus hippocastanum L) Chronic venous insufficiency Effective in short term at reducing leg pain and swelling seed extract Glucosamine sulfate Osteoarthritis Decreased pain and increased function Sources: Ernst 2001; Pittler and Ernst 2008, 1999; Schneider 1992; Towheed et al. In some to biological resources, but also to community knowledge countries, more informal links are being made between about plants therapeutic properties. A key to guaranteeing and because of the focus on intellectual property rights and access to traditional medicines is the protection and sus pharmaceuticals in general, growing attention is being paid tainable use of medicinal plant resources. But, herbal medicines are ofen collected from wild plant popu because intellectual property rights are usually given to indi lations, and overharvesting for local use or to meet export viduals or organizations, whereas indigenous knowledge is demand is a growing problem. For example, when countries community based, determining what can and should be afected by chloroquine-resistant malaria began turning to protected may be difcult. Fortunately, Artemisia annua can that is designed to protect indigenous knowledge while readily be grown from seed as an annual crop, and many exploiting modern research and development capabilities. The intellectual property agreement was made was searching for a cure for breast cancer among the fora afer scientists visited tribal chiefs to give a presentation in Samoa. The information Monographs on Selected Medicinal Plants is an important generated by these inventories should be used by national reference for national health authorities, scientists, and patent ofces worldwide to evaluate the novelty and inno pharmaceutical companies, providing technical informa vation of patent applications. Without knowledge of the potential for Currently, few standards exist to control the labeling and adverse reactions, patients may fail to inform their doctors advertising of herbal medicines. Such regulations can be issued edge about the health benefts as well as the possible risks, either by national authorities, in the form of enforceable but the information must be reliable and adapted to the controls, or by local organizations, such as professional specifc local context. Tese kinds of medicines should consider the local social, cultural, reli regulations help secure the trustworthiness of the informa gious, and spiritual contexts, because medical concepts tion, prevent false health claims and misleading advertise and understanding can vary signifcantly. Use of Complementary and Alternative References and further readings Medicine in the Scandinavian Countries. Malaria-Related Beliefs and Behaviour in Southern news/chinese-medicine-set-for-protection. Complementary and Alternative Positioning and Requirements for Effective and Safe Use. Communities Views on Prerequisites for Collaboration between London: Imperial College Press. Perceptions about html> Complementary Terapies Relative to Conventional Terapies Pagan, J. Access to Conventional Medical among Adults Who Use Both: Results from a National Survey. Artemether for Severe Malaria: A Meta-Analysis of International Monitoring of Adverse Health Efects Associated Randomised Clinical Trials. Glucosamine Terapy for Treating on Proper Use of Traditional, Complementary and Alternative Osteoarthritis. General Guidelines for Methodologies on Research Knowledge, Innovations and Practices. Guidelines for Training Traditional Health Regulatory Systems in Sub-Saharan African Countries. A regulatory authority is usu Countries may choose to develop new legislation or to ally established for administrative control. When starting afresh, it is useful to registration is ofen a major element in legislation, to prepare a general law. Models exist, and expert assistance ensure that individual products meet the criteria of ef is readily available.

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Social health insurance: The most typical understand Skimming reduces the equity benefts of insurance by ing of social health insurance is that membership is excluding those who are most in need gastritis in english buy generic bentyl 20 mg on-line. Private health insurance: Voluntary private indemnity publics and health providers lack of understanding of the insurance is provided through employers gastritis diet cabbage purchase generic bentyl line, mutual insurance concept gastritis newborn buy cheap bentyl 20mg on-line. Members may think that premiums are societies or cooperatives gastritis flare up diet 20mg bentyl mastercard, or directly by companies gastritis diet âêîíòàêòå order bentyl 20mg without prescription. Insurance is not sustainable in this environ tive services gastritis diet áèòâà buy bentyl 20 mg with visa, primary care, or outpatient medicines. Other members may Voluntary health insurance contributes to less than 5 avoid using their insurance because they believe that they percent of the health expenditures in developing coun can claim only as much as they have contributed in premi tries and usually supplements care for middle and ums. Considerable efort may be needed to educate mem high-income sectors (Gottret and Schieber 2006). Community prepaid schemes: In many countries in Many countries see the initiation or promotion of one or Asia, Africa, and Latin America, prepayment plans more insurance schemes as a way to address health fnanc based on the concept of pooling risk and resources ing issues. Yet the complexity of the issues involved is ofen have been developed for rural populations, groups poorly understood. Ideally, insurance schemes should in informal employment, or others without access to be designed in the context of an overall health policy and other health insurance. Issues to address when designing a community afliation, and the community is highly health insurance scheme include policy objectives, popula involved in managing the system. However, evidence tion coverage, benefts to be included (outpatient, inpatient, suggests that most community-based systems cover a medicines, and so forth), organization of health services, small percentage of people and do not reach the poor premium calculation and payment mechanisms, utilization est members of the community (Schieber et al. Only a few community prepaid health care schemes include pharma countries, including China, Singapore, and the United ceuticals in their list of benefts Chapter 12 discusses health fnancing through insurance Traditionally, donor assistance has come from multilateral in detail. Funding that tary community mechanisms exists in diferent countries to goes through a countrys administrative structure rather help support local health services (see Chapter 31). In some than through independent initiatives can help build national countries, villages maintain sick funds to pay the health fnancial capacity (Hecht and Shah 2006). Monies come from periodic assessments or special toward long-term health-sector development, ofen concen fund-raising events. Aside from structured insurance-like trating on specifc areas such as primary health care, essen schemes, however, informal community fund-raising has tial medicines, or immunization. Since the late 1990s, donor not been able to sustain the supply of medicines for entire funding has been directed more toward the entire health communities. In private health providers (self-insurance), or by contribut addition, development banks now require countries to use ing to private insurance for employees. Companies may also poverty reduction strategy papers as a mechanism to coor work with local government health facilities, supplementing dinate funding in a way that contributes to an overall devel government funding with company funding for medicines, opment strategy. Multilateral and bilateral organizations generally do not Such arrangements also help balance the fnancial sus support recurrent costs for personnel, regular supplies of tainability equation. They should be supported with infor essential medicines, and other operating costs. Also, donors are encour of health care systems, human resources, and physical infra aged to make long-term commitments to assistance in the structure. But fnancing mechanisms should medicine use, and to strengthen pharmaceutical regulatory meet certain stated policy objectives, and discussions about and quality assurance capacity. In addition, large initiatives, fnancing should be informed by a clear understanding of such as the U. With an increasing Access to medicines, rational medicine use, efciency, global emphasis on strengthening health systems, more equity, sustainability, and feasibility are among the most funding is available for long-term initiatives that will use common and important criteria for evaluating funding systems strengthening as a way to increase access to medi mechanisms for pharmaceuticals. In the end, are more people receiving the essential on meeting performance outcomes. Patient demand is high when medicines are resources may be insufcient to provide all essential medi free, but provider-induced demand may be high if reve cines needs, even with the best selection, procurement, dis nue from medicine charges is used for staf salaries. For such countries, outside assistance may be needed cost controls to contain demand, and promotes standard to fund some basic essential medicines requirements and is treatments by providers. Intensive fnancial support and large teams Pharmaceutical fnancing decisions ofen try to improve of advisers may achieve short-term success, but to achieve technical efciency related to pharmaceutical manage sustained success, a realistic transition to local stafng and ment. Equity in Finally, governments can coordinate assistance from health care means that essential care is provided accord donors by establishing national health and pharmaceuti ing to need and fnanced according to ability to pay. Sector-wide approaches, medium-term Sustainability: Will a reasonable level of funding be main expenditure frameworks, and poverty reduction strategy tained over time Both the amount of revenue generated papers help provide countries a framework for develop and the reliability of funding over time are important. Insurance programs require Examples of common misperceptions about access, a host of new administrative arrangements. In contrast, rational use, efciency, sustainability, and administrative government fnancing systems are usually well estab requirements could also be cited. The point is that com lished, and donor administrative requirements, though parisons of fnancing mechanisms should be based on ofen tedious, are usually well defned. With fnancing mechanisms that meet numerous programs that generate minimal revenue with other criteria, acceptance ofen grows with experience and much efort, and nonfunctioning exemption programs for understanding. As noted earlier, the fnancial performance and its own sake, but it is ofen considered with the other criteria health impact of a user-fee program are highly dependent because it may contribute to efciency, equity, and sustain on the way the program is managed and monitored. Flexibility is the extent to which funds can be used Similarly, insurance programs are complex undertakings. Donor funds tend to have the greatest A successful insurance plan must organize the registration restrictions, and community fnancing schemes have greater of members and dependents, the defnition of services cov fexibility. Improved health impact is the ultimate objective ered, accurate projections of payments to set premiums, of pharmaceutical fnancing reforms, but data that directly collection of premiums, handling of claims, payment to link funding and impact are scant. Access to essential medi providers, utilization review, quality monitoring, and cost cines becomes a more immediate measure of potential control. Application of the criteria for evaluating funding In short, it is important to distinguish between a fnancing mechanisms mechanism that is inappropriate for a given setting and one that might be appropriate but is inefectively implemented. Using these evaluation criteria helps structure the com Seek improvement, not perfection. Experience, local circum times discard a new financing alternative because it has stances, and degree of subjectivity afect the way individual certain limitations, potential inequities, or other undesir criteria are applied to fnancing mechanisms. Several over is whether it will, on balance, improve the pharmaceutical all observations can be made. Doing nothing about pharmaceutical fnancing is ofen Free government services may appear equitable, unless (as the easiest course for an uncertain policy maker or a ner in some countries) political forces result in public pharma vous manager. But if fnancial resources are inadequate, ceutical supplies being concentrated at national and regional access and quality of care will decline. User fees for poor rural mechanisms should aim at identifying actions that will lead populations may appear inequitable, but equity is actually to signifcant improvements, not at fnding perfect solutions. Some national social strategy health insurance programs provide health benefts so that low-income members are actually subsidizing high-income Because pharmaceutical fnancing is part of health fnanc members. For example, in some countries, social security ing, in many countries, complementary fnancing arrange taxes are imposed only on wages below a certain level, so ments are evolving for diferent health care needs and those with higher earning capacity do not have to pay taxes population groups. Tese wealthier people are ofen has benefts and limitations, the net efect of the pluralist 11 / Pharmaceutical fnancing strategies 11. In Disease Control Priorities If the essential medicine supply is adequate, the chal in Developing Countries. When eforts to improve therapeutic and operational pdf> efciency and to moderate demand for medicines do not Kirigia, J. The Impact of User Fees on Health coverage for medicines, or seek donor assistance. In each Service Utilization in Low and Middle-Income Countries: case, eforts should be made to ensure that available public How Strong Is the Evidence Learning from Experience: Health Care Financing in Low and Middle-Income Countries. Geneva: Global Forum for local circumstances, good leadership and management, Health Research. Financing of Global Health: Tracking Development Assistance for Health from H = Key readings. Getting Health Based Health Insurance in Developing Countries: A Study of Its Reform Right: A Guide to Improving Performance and Equity. Investing in Health Financing: Lessons from Reforms in Low and Middle-Income Development: A Practical Plan to Achieve the Millennium Countries. The Next 4 Billion: Market Size and Business Strategy at the htm> 11 / Pharmaceutical fnancing strategies 11. Reaching Universal Coverage via Social Health and Policies: Good Governance for Medicines Program. Achieving Universal Health Coverage: Developing Essential Medicines and Pharmaceutical Policies & Ethics, Equity, the Health Financing System. Some insurance schemes incorporate medicines as or households, protecting the individual from a cata part of a comprehensive care package, others compensate strophic fnancial loss in the event of a serious illness. Insurance, therefore, spreads the burden of payment for However, strong arguments favor including medicines in illness among all the members of the scheme whether insurance schemes because proper use of medicines can they are ill or healthy, poor or rich. By their very nature, help prevent serious illness and death, and because phar insurance schemes act as fnancing agents: they receive maceuticals make up such a large share of out-of-pocket funds from employers, households, and the government spending in countries around the world. Terefore, the main components of insur nifcant potential to reduce the burden of disease and ance schemes are collecting revenue, pooling resources poverty. Using their power as large-scale purchasers, and risks, and purchasing quality goods and services. Health insurance is appealing to gov Furthermore, carefully designed insurance-based fnanc ernments because it takes the entire fnancial burden ing for medicines is both scalable and sustainable. However, when governments consider hazard (which in this case refers to more frequent use instituting health insurance, they need to be aware of the of services or medicines by members of an insurance realities of implementation; the complexity of the issues scheme than would occur were they not insured), well involved is ofen poorly understood. Public and private insur a resource-poor setting is still a matter of considerable ance programs control pharmaceutical expenditures debate. Whatever type of health fnancing mechanism a through measures related to payment, management, country decides to adopt, the transition to universal cov prescribing patterns, dispensing practices, and use. In addition to those direct costs, income is health coverage lost when family members are sick, and this loss reinforces the poverty-illness cycle. Women are especially vulnerable, In many countries, especially those with the fewest because they are usually the main family caregivers. Traditionally, governments have pro is fnanced out-of-pocket, a system that places the larg vided a national health service for all citizens with fnanc est burden on the poorest people. Many of these health systems have spending accounts for more than 60 percent of total health not worked well or consistently provided needed medicines, spending in low-income countries (Gottret and Schieber a gap that has led to increased out-of-pocket spending for 2006), of which 60 to 90 percent may be spent on medicines health care services and medicines in the private sector, 12 / Pharmaceutical benefts in insurance programs 12. Evidence from mul dictable, infrequent, costly, unwanted, and uncontrollable tiple countries has shown that a lack of health insurance is by the insured. A good example is insuring a house against a key condition related to catastrophic household spending fre. Many people are prepared to pay a fnancing systems more equitable and increase coverage to regular premium for a lifetime to gain peace of mind against the entire population, many low and middle-income coun a catastrophe that they hope will never happen. Health insurance coverage that includes pharma the risk (for example, pregnancy); and the presence of insur ceuticals has expanded access to medicines in many coun ance increases the use of services. Health insurance schemes appeal to both citizens and The principal aims of well-managed insurance schemes their governments because they help manage the fnancial are to reduce catastrophic fnancial loss in the event of a burden by spreading the total cost of insured health care serious illness and to guarantee the funds or access needed among various partners. In addition, donors and inter to secure necessary, if expensive, medical services. Health national fnancial institutions, such as the World Bank, insurance provides this fnancial protection by evening out are fnding health insurance to be an increasingly feasible household health expenditures. The chapter describes the healthy people subsidize those who consume more sys main components of health insurance and potential prob tem resources and are relatively sick (risk pooling). Health insurance is a mechanism for spreading the risks of Social or public health insurance: The most typical under potential health care costs over a group of individuals or standing of social health insurance is that membership households, with the goal of protecting the individual from is compulsory for a designated population; fnancial a catastrophic fnancial loss in the event of serious illness. In multiple Germany launched its program in 1883 (Carrin and payer systems, several diferent organizations perform all James 2005). Teir insur Private health insurance: Private indemnity insurance ance pools have diferent levels of risk, and consumers may is (usually) paid for by voluntary contributions from be able to choose their own insurer.

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