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By C. Kirk. Miami University of Ohio. 2018.

Highest priority is thus given to studies that address the following research topics: • long-term generic aspirin 100 pills without a prescription, dose–response studies to help identify the requirement of individual macronutrients that are essential in the diet (e trusted aspirin 100 pills. It is recognized that it is not possible to identify a defined intake level of fat for maintaining health and decreasing risk of disease purchase 100pills aspirin visa; however, it is recognized that further information is needed to identify acceptable ranges of intake for fat, as well as for protein and carbohydrate that are based on prevention of chronic diseases and maintaining health; • studies to further understand the beneficial roles of Dietary and Functional Fibers in human health; • studies during pregnancy designed to determine protein and energy needs; • information on the form, frequency, intensity, and duration of exercise and physical activity that is successful in managing body weight in both children and adults; • long-term studies on the role of glycemic response in preventing chronic diseases, such as diabetes and coronary heart disease, in healthy individuals, and; • studies to investigate the levels at which adverse effects occur with chronic high intakes of specific macronutrients. For some nutrients, such as saturated fat and cholesterol, biochemical indicators of adverse effects can occur at very low intakes. Thus, more information is needed to ascer- tain defined levels of intakes at which onset of relevant health risks (e. A state- ment for health professionals from the Nutrition Committee, American Heart Association. This comprehensive effort is being undertaken by the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes of the Food and Nutrition Board, Institute of Medicine, the National Academies, in collaboration with Health Canada. See Appendix B for a description of the overall process, its origins, and other relevant issues that developed as a result of this new process. Establishment of these reference values requires that a criterion of nutritional adequacy be carefully chosen for each nutrient, and that the population for whom these values apply be carefully defined. A requirement is defined as the lowest continuing intake level of a nutrient that, for a specific indicator of adequacy, will maintain a defined level of nutriture in an individual. The median and average would be the same if the distribution of requirements followed a symmetrical distribution and would diverge if a distribution were skewed. This is equivalent to saying that randomly chosen individuals from the population would have a 50:50 chance of having their requirement met at this intake level. The specific approaches, which are provided in Chapters 5 through 10, differ since each nutrient has its own indicator(s) of adequacy, and different amounts and types of data are available for each. That publication uses the term basal requirement to indicate the level of intake needed to prevent pathologically relevant and clinically detectable signs of a dietary inadequacy. The term normative requirement indicates the level of intake sufficient to maintain a desirable body store, or reserve. Its applicability also depends on the accuracy of the form of the requirement distribution and the estimate of the variance of requirements for the nutrient in the population subgroup for which it is developed. For many of the macronutrients, there are few direct data on the requirements of children. Where factorial modeling is used to estimate the distribution of a requirement from the distributions of the individual components of the requirement (maintenance and growth), as was done in the case of protein and amino acid recommendations for children, it is necessary to add (termed convolve) the individual distributions. Examples of defined nutritional states include normal growth, maintenance of normal circulating nutrient values, or other aspects of nutritional well-being or general health. The goal may be differ- ent for infants consuming infant formula for which the bioavailability of a nutrient may be different from that in human milk. In general, the values are intended to cover the needs of nearly all apparently healthy individuals in a life stage group. Qualified health professionals should adapt the recommended intake to cover higher or lower needs. Instead, the term is intended to connote a level of intake that can, with high probability, be tolerated biologically. This indicates the need for caution in consuming amounts greater than the recommended intake; it does not mean that high intake poses no potential risk of adverse effects. In many cases, a continuum of benefits may be ascribed to various levels of intake of the same nutrient. One criterion may be deemed the most appropriate to determine the risk that an individual will become deficient in the nutrient, whereas another may relate to reducing the risk of a chronic degenerative disease, such as certain neurodegenerative dis- eases, cardiovascular disease, cancer, diabetes mellitus, or age-related macular degeneration. Role in Health Unlike other nutrients, energy-yielding macronutrients can be used somewhat interchangeably (up to a point) to meet energy requirements of an individual. However, for the general classes of nutrients and some of their subunits, this was not always possible; the data do not support a specific number, but rather trends between intake and chronic disease identify a range. Given that energy needs vary with individuals, a specific number was not deemed appropriate to serve as the basis for developing diets that would be considered to decrease risk of disease, including chronic diseases, to the fullest extent possible. These are ranges of macronutrient intakes that are associated with reduced risk of chronic disease, while providing recommended intakes of other essential nutrients. Above or below these boundaries there is a potential for increasing the risk of chronic diseases shown to effect long-term health. The macro- nutrients and their role in health are discussed in Chapter 3, as well as in Chapters 5 through 11. The amount consumed may vary substantially from day-to-day without ill effects in most cases. Healthy subgroups of the population often have different requirements, so special attention has been given to the differences due to gender and age, and often separate reference intakes are estimated for specified subgroups. When this is an issue, it is discussed for the specific nutrient in the section “Special Considerations. People with diseases that result in malabsorption syndrome or who are undergoing treatment such as hemo- or peritoneal dialysis may have increased requirements for some nutrients. Special guidance should be provided for those with greatly increased nutrient needs or for those with decreased needs such as energy due to disability or decreased mobility. Life Stage Groups The life stage groups described below were chosen while keeping in mind all the nutrients to be reviewed, not only those included in this report. Infancy Infancy covers the period from birth through 12 months of age and is divided into two 6-month intervals. Except for energy, the first 6-month interval was not subdivided further because intake is relatively constant during this time. That is, as infants grow, they ingest more food; however, on a body-weight basis their intake remains nearly the same. During the second 6 months of life, growth velocity slows, and thus daily nutrient needs on a body-weight basis may be less than those during the first 6 months of life. The extent to which intake of human milk may result in exceeding the actual requirements of the infant is not known, and ethics of human experimentation preclude testing the levels known to be potentially inadequate. It also supports the recommendation that exclusive human-milk feeding is the preferred method of feeding for normal, full-term infants for the first 4 to 6 months of life. In general, for this report, special consideration was not given to pos- sible variations in physiological need during the first month after birth, or to the variations in intake of nutrients from human milk that result from differences in milk volume and nutrient concentration during early lactation. However, where warranted, information discussing specific changes in bioavailability or source of nutrients for use in develop- ing formulations is included in the “Special Considerations” section of each chapter. Because there is variation in both of these measures, the computed value represents the mean. It is assumed that infants will have adequate access to human milk and that they will con- sume increased volumes as needed to meet their requirements for mainte- nance and growth. This is because the amount of energy required on a body-weight basis is significantly lower during the second 6 months of life, due largely to the slower rate of weight gain/kg of body weight. Toddlers: Ages 1 Through 3 Years Two points were primary in dividing early childhood into two groups. First, the greater velocity of growth in height during ages 1 through 3 years compared with ages 4 through 5 years provides a biological basis for divid- ing this period of life.

The converse is that these figures could be considered to be potential welfare gains if chronic diseases in these countries were success- fully reduced order 100pills aspirin with amex. The numbers should be interpreted with caution generic aspirin 100 pills without prescription, because the approach is not yet well accepted discount aspirin 100 pills with mastercard; however, it provides an upper limit for the cost estimates. This corresponds to the prevention of 36 million premature deaths over the next 10 years. Some 17 million of these prevented deaths would occur in people under 70 years of age. To estimate the potential economic gain were this scenario to be achieved, the growth model was used, and the loss in national income given the global goal scenario was compared with the loss that would occur given the business-as-usual situation discussed previously. This in turn would translate to an accumulated gain in income of over 36 billion dollars in China, 15 billion dollars in India and 20 billion dollars in the Russian Federation over the next 10 years (see figure above). The evidence is clear that action is urgently needed to avoid an adverse impact on national economic development. The cost of achieving the global goal has not been estimated here, although Part Three will show that simple, well-applied policies and interventions targeted at the prevention and control of chronic diseases are cost-effective and affordable. The global spread of type 2 diabetes International Journal of Epidemiology, 2002, 31:240–247. A higher prevalence patterns of nutritional risks in relation to economic development. Geneva, World Health deprivation and incidence of coronary heart disease: a multilevel Organization, 2004. The health effects of restricting prescription medication use for the decline in coronary heart disease mortality rates in because of cost. New Delhi, World heart disease mortality reduction in Scotland: prevention or Health Organization Regional Office for South-East Asia, 2000 treatment? Widening socioeconomic inequalities in mortality in six Center, University of North Carolina at Chapel Hill, 2003. Associations between socioeconomic status and cardiovascular Diabetes Research and Clinical Practice, 2000, 48:37–42. Health Policy and Planning, 2005, care for coronary heart disease related and not related to 20:41–49. Organization European Office for Investment for Health and Canberra, Australian Institute of Health and Welfare/Centre for Development, 2005. Canberra, Australian Journal of Health, Population and Nutrition, 2001, 19:291–300. The economic costs associated with physical inactivity and obesity in Canada: an update. This part of the report provides a summary of the evidence, and explains how interventions for both the whole population and individuals can be combined when designing and implementing a chronic disease prevention and control strategy. They address the causes rather than the consequences of chronic diseases and are central to attempts to prevent the emergence of future epidemics. Small reductions in the exposure of the population to risk factors such as tobacco » Rapid health gains use, unhealthy diet and physical can be achieved with inactivity lead to population-level comprehensive and reductions in cholesterol, blood integrated action pressure, blood glucose and body » In this way, many weight. More fundamentally, countries and regions interventions are also required have already successfully to address the underlying deter- curbed chronic diseases minants of chronic disease, as described in Part Two. Interventions for individuals focus on people who are at high risk and those with estab- lished chronic disease. These interventions reduce the risk of developing chronic disease, reduce complications, and im- prove quality of life. A strategy to achieve rapid results Population-wide and individual approaches are complementary. They should be combined as part of a comprehensive strategy that serves the needs of the entire population and has an impact at the individual, community and national levels. Comprehensive approaches should also be integrated: covering all the major risk factors and cutting across specific diseases. Risk factor reduction can lead to surprisingly rapid health gains, at both population and individual levels. This can be observed through national trends (in Finland and Poland, for example, as described on page 93), sub-national epidemiological data and clinical trials. In the case of tobacco control, the impact of proactive policies and programmes is almost immediate. The implementation of tobacco-free policies leads to quick decreases in tobacco use, rates of cardiovascular disease, and hospitalizations from myocardial infarction. Improving diet and physical activity can prevent type 2 diabetes among those at high risk in a very short space of time. Lowering a person’s serum cholesterol concentration results in quick and substantial protec- tion from heart disease. Benefits are related to age: a 10% reduction in serum cholesterol in men aged 40 can result in a 50% reduction in heart disease, while at age 70 there is on average a 20% reduction. Benefits can be realized quickly – after two years – with full benefits coming after five years (4). While Australia, Canada, the United Kingdom and the United States, for example, have achieved steady declines in heart disease death rates, the rates in other countries, such as Brazil and the Rus- sian Federation, have remained the same or increased (see figure below). Initial reductions occurred partly as a result of the diffusion of health-related information to the general population. These approaches have been used to reduce chronic disease death rates in many countries, demonstrating the feasibility of achieving more widespread success. Vegetable fat and oil consumption disease among young and middle-aged men elimination of blinding trachoma by increased (primarily in the form of rape- and women. This success has resulted from seed and soybean oil products), while political and economic changes in 1991, a combination of high-level political animal fat consumption, mainly butter, this trend sharply reversed. These trends were associated between 20 and 44 years, the decline in death munity participation in prevention with the removal of price subsidies on rates averaged 10% annually, while in those and control efforts. Other factors contribut- Trachoma is a chronic disease with rate of decline was 6. This was one of ing to the decline include increased fruit an infectious origin that results in the most dramatic rates of decline ever seen consumption and decreased tobacco use irreversible blindness if untreated. Improvements in medi- was common in Morocco in the 1970s since occurred in other countries in eastern cal treatment contributed little, if at all, to and 1980s. This was largely a result of widespread and heavy tobacco use, high- external partners. In response to local concerns, a large-scale provision of surgical services to stop the pro- community-based intervention was organized, involving consumers, schools, and gression of blindness, health promotion and social and health services. It included legislation banning tobacco advertising, environmental measures to prevent infection, the introduction of low-fat dairy and vegetable oil products, changes in farmers’ and treatment with antibiotics in trachoma- payment schemes (linking payment for milk to protein rather than fat content), and endemic areas.

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The investigators reported reduced plasma triacylglycerol concentrations in 32 hypertriacylglycerolemic individuals by greater than 20 percent buy generic aspirin 100pills on line, and the reduction remained significant with the control of weight loss cheap 100pills aspirin. Parks and Hellerstein (2000) published an exhaus- tive review of carbohydrate-induced hypertriacylglycerolemia and concluded that it is more extreme if the carbohydrate content of a high carbohydrate diet consists primarily of monosaccharides order aspirin 100pills visa, particularly fructose, rather than oligo- and polysaccharides. Purified diets, whether based on starch or monosaccharides, induce hypertriacylglycerolemia more readily than diets higher in fiber in which most of the carbohydrate is derived from unprocessed whole foods, and possibly result in a lower glycemic index and reduced postprandial insulin response (Jenkins et al. Only the negative relationship to glycemic load was significant for postmenopausal women (Liu et al. In contrast, Ford and Liu (2001) reported a more pronounced response in men than in women. Insulin has three major effects on glucose metabolism: it decreases hepatic glucose output, it increases glucose utilization in muscle and adipose tissue, and it enhances glycogen production in the liver and muscle. Indi- viduals vary genetically in their insulin sensitivity, some being much more efficient than others (Reaven, 1999). Two prospective cohort studies showed no risk of diabetes from con- suming increased amounts of sugars (Colditz et al. Furthermore, a negative association was observed between increased sucrose intake and risk of diabetes (Meyer et al. Intervention studies that have evaluated the effect of sugar intakes on insulin concentration and insulin resistance portray mixed results. Dunnigan and coworkers (1970) reported no difference in glucose tolerance and plasma insulin concentration after 0 or 31 percent sucrose was consumed for 4 weeks. Reiser and colleagues (1979b) reported that when 30 percent starch was replaced with 30 percent sucrose, insulin concentration was significantly elevated; however, serum glucose concentration did not differ. Based on associations between these metabolic parameters and risk of disease (DeFronzo et al. Several studies have been conducted to determine the rela- tionship between total (intrinsic plus added) and added sugars intake and energy intake (Table 6-10). The Department of Health Survey of British School Children showed that as total sugar intake increased from less than 20. Study reported a significant decrease in energy intake with increased total sugar intake (Nicklas et al. A study of 42 women compared the effects of a high sucrose (43 percent of total energy) and low sucrose (4 percent of total energy), low fat (11 percent total energy) hypoenergetic diet (Surwit et al. There were no significant differences between groups in total body weight lost during the intervention. Increased added sugars intakes have been shown to result in increased energy intakes for children and adults (Bowman, 1999; Gibson 1996a, 1997; Lewis et al. For adolescents, nonconsumers of soft drinks consumed 1,984 kcal/d in contrast to 2,604 kcal/d for those teens who consumed 26 or more oz of soft drinks per day (Harnack et al. Kant (2000) demonstrated a positive association between energy- dense, micronutrient-poor food and beverage consumption (visible fats, nutritive sweeteners, sweetened beverages, desserts, and snacks) and energy intake. Ludwig and colleagues (2001) examined the relationship between con- sumption of drinks sweetened with sugars and childhood obesity. Drinks sweetened with sugars, such as soft drinks, have been suggested to promote obesity because compensation at subsequent meals for energy consumed in the form of a liquid could be less complete than for energy consumed as solid food (Mattes, 1996). Published reports disagree about whether a direct link exists between the trend toward increased intakes of sugars and increased rates of obesity. The lack of association in some studies may be partially due to the perva- sive problem of underreporting food intake, which is known to occur with dietary surveys (Johnson, 2000). Underreporting is more prevalent and severe by obese adolescents and adults than by their lean counterparts (Johnson, 2000). In addition, foods high in added sugars are selectively underreported (Krebs-Smith et al. Based on the above data, it appears that the effects of increased intakes of total sugars on energy intake are mixed, and the increased intake of added sugars are most often associated with increased energy intake. National Diet and 12–16 Nutrition Survey of 16–20 Children 20–25 > 25 Bowman, 1999 Continuing Survey < 10 of Food Intakes by 10–18 Individuals > 18 (1994–1996) a,b,c Different lettered superscripts within each study indicate that values were signifi- cantly different. It is possible that the level and duration of exercise and amount of test food have critical influences on the results obtained in such studies. Where energy intake was assessed at more than one time point, data from the longest period were used. Research, 1997) and therefore are insufficient to determine a role of sugars in breast cancer (Burley, 1998). There are indications that insulin resis- tance and insulin-like growth factors may play a role in the development of breast cancer (Bruning et al. Both fruit intake and nonfruit sources of fructose predicted reduced risk of advanced prostate cancer (Giovannucci et al. Colorectal Cancer The World Cancer Research Fund and American Institute for Cancer Research (1997) reviewed the literature linking foods, nutrients, and dietary patterns with the risk of human cancers worldwide. Data from five case-control studies showed an increase in colorectal polyps and colorectal cancer risk across intakes of sugars and foods rich in sugars (Benito et al. The subgroups studied showed an elevated risk for those consum- ing 30 g or more per day compared with those eating less than 10 g/d. Others have concluded that high consumption of fruits and vegetables, as well as the avoidance of foods containing highly refined sugars, are likely to reduce the risk of colon cancer (Giovannucci and Willett, 1994). In many of the studies, sugars increased the risk of colorectal cancer while fiber and starch had the opposite effect. One investigator suggested that the positive association between high sugars consumption and colorectal cancer reflects a global dietary habit that is generally associated with an increased risk of colorectal cancer and may not indicate a biological effect of sugars on colon carcinogenesis (Macquart-Moulin et al. Burley (1997) concluded from a review of the available literature that there was insufficient evidence to conclude whether sugars had a role in colon cancer. At a time when populations are increasingly obese, inactive, and prone to insulin resistance, there are theoretical reasons that dietary interventions that reduce insulin demand may have advantages. In this section of the population, it is likely that more slowly absorbed carbohydrate foods and low glycemic load diets will have the greatest advantage. Data from long-term clinical trials on the effects on energy intake are lacking and further studies are needed in this area. Because not all micronutrients and other nutrients such as fiber were not examined, the association between added sugars and these nutrients it is not known. While it is recognized that hypertriglyceridemia can occur with increasing intakes of total (intrinsic plus added) sugars, total sugars intake can be limited by minimizing the intake of added sugars and con- suming naturally occurring sugars present in nutrient-rich milk, dairy prod- ucts, and fruits. Intake Assessment Median intakes of added sugars were highest in young adults, particu- larly adolescent males (35. At the 95th percentile of intake, added sugars intakes were as high as 52 tsp (208 g or 832 kcal) for men aged 19 to 50 years. Interaction of dietary sucrose and fiber on serum lipids in healthy young men fed high carbohydrate diets.

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In any type of emergency cheap aspirin 100pills without prescription, the goal is to have a plan in place that will: minimize damage purchase aspirin 100 pills line, ensure the safety of staff order aspirin 100 pills with visa, children, and students, protect vital records/assets, allow for self- sufficiency for at least 72 hours, and provide for continuity of your critical business operations. In addition, each organization should develop an appendix to their plan on how they would handle a long term event that could result in a significant reduction of workforce, such as an influenza pandemic. It is essential to have a written plan that has been discussed and practiced with all employees and discussed with children and their families. This preparation will allow everyone to know their roles and responsibilities when an emergency occurs. In addition to the organization having an emergency response plan, it is necessary for employees to have individual and family preparedness plans. With everyone prepared, your organization will be in a better position to manage any type of emergency. There are a number of resources listed on pages 225 to 229 that are available to help you create your organization’s emergency plan. Check with your local or state health department or childcare licensing groups, department of human services or department of education to see if they may be available to answer questions. It includes specific activities for training individuals who direct and work in child care centers. It includes activities for training individuals who care for children in their homes. This template was a joint collaborative project of the American Academy of Pediatrics, the American Public Health Association, and National Resource Center for Health & Safety in Child Care. The following are highlighted materials from the Academy’s website: Four Steps to Prepare Your Family for Disasters: Contains a section on what to tell children. Antibiotics are used to treat infections/diseases caused by bacteria, but they cannot kill viruses and cannot cure or stop the spread of diseases caused by viruses. For example, a child may have hepatitis A virus in the stool and not have symptoms, but still be able to infect others. They are much larger than viruses, and they can often be treated effectively with antibiotics. For example, some children may be carriers of Giardia intestinalis (parasite) and have no symptoms. Many communicable diseases are reportable to the local or state health department. This could be due to overheating, reactions to medications, or a response to infection. Body temperature along with signs and symptoms of illness should be evaluated jointly to determine if exclusion is necessary. For example, health officials may offer immune globulin injections to children and staff in a childcare setting when cases of hepatitis A occur. For example, a child acquires immunity to diseases such as measles, mumps, rubella, and pertussis after natural infection or by vaccination. Influenza should not be confused with a bacterial infection called Haemophilus influenzae or with "stomach flu" (usually vomiting and diarrhea). Ear infections may be caused by Streptococcus pneumoniae or Haemophilus influenzae. The purpose of using barriers is to reduce the spread of germs to staff and children from known/unknown sources of infections and prevent a person with open cuts, sores, or cracked skin (non-intact skin) and their eyes, nose, or mouth (mucous membranes) from having contact with another person’s blood or body fluids. Swimming in or drinking water from a contaminated water source can also spread organisms. Antibiotics will not fight against viruses - viral infections clear up on their own and antibiotics will not help. Human Immunodeficiency Virus and Other Blood-borne Viral Pathogens in the Athletic Setting, Pediatrics 104(6):1400-03, 1999. Caring for Our Children- National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs, Second Edition, 2002. Epidemiology and Prevention of Vaccine-Preventable Diseases, Eleventh Edition, May, 2009. Preventing tetanus, diphtheria and pertussis among adolescents: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. Preventing tetanus, diphtheria and pertussis among adults: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. Use of diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine as a five-dose series. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. Measles, Mumps and Rubella - vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps. Control and prevention of rubella: Evaluation and management of suspected outbreaks, rubella in pregnant women, and surveillance of congenital rubella syndrome. Compendium of measures to prevent disease associated with animals in public settings. Guidance for the Registration of Pesticide Products Containing Sodium and Calcium Hypochlorite Salts as the Active Ingredient. Because of international travel and migration, cities are becoming important Division of International and hubs for the transmission of infectious diseases, as shown by recent pandemics. Physicians in urban environments Humanitarian Medicine, Department of Community in developing and developed countries need to be aware of the changes in infectious diseases associated with Medicine and Primary Care, urbanisation. Furthermore, health should be a major consideration in town planning to ensure urbanisation works to Geneva University Hospitals, reduce the burden of infectious diseases in the future. Many national and municipal governments (E Alirol, L Getaz, F Chappuis, living in cities. The urban sector’s share of the poor is Geneva, Geneva, Switzerland their urban agglomerations (figure 1). In Sudan and Central African Correspondence to: Niamey, Niger, for example, increased from Republic, more than 94% of urban residents live in Prof Louis Loutan, Service de 250 000 people in the 1980s to almost 1 million today. In 2001, 924 million5 Médecine Internationale et humanitaire, Hôpitaux 2050, the world’s urban population is expected to reach urban residents lived in slums and informal settlements. Almost all of this growth will be in low- This number is expected to double to almost 2 billion by Rue Gabrielle Perret-Gentil 4, income regions: in Africa the urban population is likely 2030. Chronic illnesses have been increasing in sub-Saharan Africa remains mainly rural and is not importance, but infectious diseases remain a leading expected to pass the urban tipping point before 2030. This worldwide increase in urban population environments and others have emerged or re-emerged results from a combination of factors including natural in urban areas. The heterogeneity in health of urban population growth, migration, government policies, dwellers, increased rates of contact, and mobility of infrastructure development, and other major political people, results in a high risk of disease transmission in and economical forces, including globalisation. Cities become incubators There is no universally accepted definition of what where all the conditions are met for outbreaks to occur. Some countries use a basic administrative Although poor urban areas are typically affected first, definition (eg, living in the capital city); others use population measures (eg, size or density), or functional 6000 More developed regions, urban population characteristics (eg, economic activities).

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