Celexa

Luiz H. M. Pimenta, MD, PhD

• Associate Professor
• University of California?an Diego
• San Diego, California
• Founder and Director
• Instituto de Patologia Coluna
• Sao Paulo, Brazil

These section heading medicine descriptions order 40mg celexa amex, by redesignating the existing records shall document: text as paragraph (a) and adding the word (1) the date of receipt; molluscan before the word shellfsh the two times that it appears k-9 medications trusted celexa 40 mg, and by adding new (2) the quantity and type of shellfsh; paragraphs (b) treatment bee sting discount celexa on line, (c) symptoms als buy celexa 20 mg low cost, and (d) to read as follows: and. All shellstock shall bear a tag that discloses the packer or repacker of the product. In place of the tag, bulk shellstock shipments may be accompanied by a bill of lading or similar shipping document that contains the same information. All containers of shucked molluscan shellfsh shall bear a label that identifes the name, address, and certifcation number of the packer or repacker of the molluscan shellfsh. Any molluscan shellfsh without such a tag, shipping document, or label, or with a tag, shipping document, or label that does not bear all the information required by paragraphs (b) and (c) of this section, shall be subject to seizure or refusal of entry, and destruction. I welcome the publication of this sensible guidance on setting product shelf life, and explaining what factors affect the expiry date of a food product. The food and drink industry has a pivotal role in ensuring that consumers understand the date marks on food and drink products and use them in support of food safety as well as waste reduction. This often includes shelf-life studies which aid in determining the length of time the product will meet certain standards in relation to parameters such as microbiology, taste, appearance, vitamin levels and smell. It must however be noted that this guidance does not replace the need for technical expertise which should be sought if it is not available within a food business. After a relatively short its optimal condition and so relates to the quality of best before date accommodates the wide range of period, these foods are likely to present a the food. This is the point at which the taste or eating shelf life applied to such products. Accordingly, the risk of food poisoning, and so this relates quality may begin to decline. The food will still be safe Regulations recognise that the format of the coding to the safety of the food. Typically, Legally food that has passed the best before date For a shelf life under 3 months, an indication of the this form of date coding is found on fresh and is still ft for human consumption can be sold. In view of the vast suffcient; for more than 18 months, an indication of date food is deemed unsafe and it is a range of food products, the expected shelf life related the year is the minimum required. We discourage the use of Use By dates as a default for unsubstantiated application. If incorporated into another product without modify the atmosphere in the pack and so the mix and quantity of ingredients used in being processed or signifcantly changed. If a raw material is changed during processing ham) is not suffcient information on which to . In some cases, differently on contact with food and product but also during preparation. However, Secondary and tertiary or transport packaging that allowing for abuse or mishandling is a it is advisable instead to think of this as a safety must not be ignored for these will often be legal requirement under the Consumer Rights zone designed to protect both the consumer designed to protect the primary packaging in Act 2015, the commentary for which states: and the manufacturer or seller of the food. The business protect the glass jar during its journey along quality of the goods is satisfactory to consumer supply chain should be considered the rest of the supply chain. Knowledge of the is determined by what a reasonable in setting the appropriate shelf life. This will supply chain and handling requirements will be person would consider satisfactory require investigation. The effectiveness of cleaning, the length important to consider: ice cream lolly that is likely to be consumed of time equipment is used before being cleaned immediately on opening. Building Design and the sources of bacteria should therefore the environment used for storing and handling both be carefully assessed. It is advisable to make Where there is any likelihood of a foodstuff not foods and food contact packaging will commonly use of laboratory testing to analyse fndings and being consumed immediately on opening, this range from a high risk environment where the aim validate hygiene programs. In some cases, there may even be zero care longer it takes to clean, the less likely it is to It is a legal requirement to provide the consumer environments such as outside catering. This includes risk of contamination that could immediately, or after hygienic condition indefnitely without specifc instructions on preparation such as defrosting or a period of time, create a food safety problem. The frequency of cooking, how to store the food once the package Process Design use and the controls in place to prevent reis opened, or to consume immediately. Bacteria are highly unlikely to be completely contamination of clean equipment should absent from anything other than highly therefore be understood before deciding upon specialised food production areas or types of the shelf-life to apply. As the microorganism is identifed as likely to be be undertaken to identify the actual life of the organoleptic qualities of the food will generally present in a food then challenge testing may be product. This must take into account both the require the food to be eaten, it is highly advisable appropriate. However, expert advice should be shelf-life assigned to the unopened pack and to frst undertake microbiological testing of the food sought to ensure that all the limitations of such any secondary use-by instructions that apply to provide assurance that it is safe to eat on the testing are fully understood. Once a shelf-life has been validated and the in respect of nutritional content) then this will also Shelf-life prediction software is a useful tool for product is placed on sale, repeat testing should need to be factored into testing for any nutrients identifying the possible life that may be achieved then be scheduled even if no obvious changes that may degrade over time. However, such software should not be used in Advice on which bacteria should be included in this will ensure that any variation that may occur isolation to set the shelf-life of a food due to the the testing should be gained from an expert such within the supply chain, affecting ingredient quality high number of variables that will affect the actual as an industry association, accredited laboratory without your knowledge, is taken into account. Where a should be made to customer and legal requirements, long production run is applied, consideration must both of which may require pathogen testing to be be given to all factors that may impact the shelf life. It is also advisable to ensure that Both the organoleptic quality and the food safety accredited test methods are being used. Vacuum packaging: product is placed the performance of the package system Organoleptic: the taste, smell, appearance into a strong pouch from which all the air is (Robertson, 2006). Challenge testing: deliberate inoculation of the removal of the oxygen present in the air Secondary or Open life: the period of time product with relevant microorganisms that have prevents many food poisoning bacteria and during which a food will remain safe and of the potential to survive or grow within the product spoilage organisms from growing and stops a suitable quality for consumption after the during normal storage conditions (challenge aerobic reactions that could lead to off taints primary product packaging has been opened. Shelf life: the period of time during which a stimulate the growth of the potent pathogen, food will remain safe and of a suitable quality Clostridium botulinum, and this needs to be Humectant: a substance such as a food for consumption while stored as instructed considered in any anaerobic pack. International Commission on Microbiological (December 2014): Summary guidance for food business To be read in conjunction with a guide to help you & your Specifcations for Foods: Microorganisms in Food operators and enforcement offcers in Scotland, Wales and business challenge existing product life & open life (above). This covers time-temperature indicators of date labels to food issued in September 2011 foods with respect to non-proteolytic Clostridium and time-temperature abuse. Point) based approach for these foods to minimise the risk Chapters in this section also investigate the effects of Defra Guidance on Food Labelling: Giving Food of Clostridium botulinum. It explains the 10-day shelf-life rule ingredients, processing and packaging on stability, among Information to Consumers (October 2016) contains a and the requirement for additional controlling factors, where other factors. Part 2 describes methods for stability section on date labelling the shelf-life is greater than 10 days. This sets limits Supplementary information such as tables of information on micro-organisms, such as listeria, in food. Food Safety Authority of Ireland Guidance Note 18 on affect shelf-life provides a basis for further consideration Validation of Product Shelf Life (version 2) from 2014 of the practical aspects of shelf-life determination. We also work in partnership with key players in the food chain to ensure our food is safe and that consumers can have trust in it. Food & Drink Federation 020 7836 2460 6th Floor, 10 Bloomsbury Way generalenquiries@fdf. It was developed as a tool to encourage common understanding among caregivers, teachers, families, and healthcare professionals about infectious diseases and to aid with efforts for reducing illnesses, injuries and other health problems in childcare settings. This guide explains the health history of immunizations, ways to prevent and control the spread of communicable diseases, symptoms of common infections seen in childcare settings, how infections are spread, when to seek medical care, inclusion/exclusion criteria, fact sheets, and sample letters to give to parents. As families enter the workforce, they must rely on childcare centers to provide a safe, healthy and caring environment for their child. These children are very susceptible to contagious diseases because they have not been exposed to many infections. A variety of infections have been documented in children attending childcare, sometimes with spread to caregivers and to others at home. In addition, wherever there are children in diapers, the spread of diarrheal diseases may readily occur as the result of poor or inadequate handwashing, diaper changing and environmental sanitation measures. In general, sending home (excluding) mildly ill children is not an effective way to control the spread of most germs. All of these factors make infections in childcare settings common and fast spreading. This manual contains disease fact sheets specifically meant for childcare settings. These fact sheets may be distributed to parents and staff; fact sheets will help staff determine when children should be sent home or readmitted to your facility.

Disseminated infections carry a high risk of rapidly progressive septic shock and 35 subsequent mortality medicine hat tigers discount celexa uk. Chronic symptomatic infection is common (50% of all natural cases) and is eventually always fatal without treatment treatment 12mm kidney stone discount celexa 40mg fast delivery. Chronic infections with less virulent strains may also be periodically asymptomatic medications ok during pregnancy discount celexa 20mg visa. Mortality rates dropped to 20% for localized disease and 40% overall after sulfadiazine therapy became available; experience with treatment using modern antibiotics is limited medicine interactions purchase celexa cheap. Also, melioidosis may remain asymptomatic after initial acquisition, and can remain quiescent for decades; these patients may present with active melioidosis up to 29 years later, often associated with onset of an immune-compromising state. Mucocutaneous exposure may lead to local nodule / abscess formational and regional lymphadenitis, but this is not as commonly seen as with glanders. In fact, most suspected percutaneous exposures which have led to symptomatic disease initially presented with either pneumonia (presumably via hematogenous spread) and / or sepsis. Rarely, melioidosis will present as a distal, focal abscess with or without obvious site of primary inoculation; most commonly as a primary purulent parotitis in children (more common in Thailand) or as a primary prostatic abscess (more common in northern Australia). For non-septicemic patients with focal disease, and with appropriate surgical and medical therapy, prognosis is good. Inhalational exposure, either through near drowning or via infectious aerosols, typically results in an acute or subacute pneumonia and septicemia. Septicemic melioidosis typically presents with fever, rigors, night sweats, myalgia, anorexia, and headache. Additional signs and symptoms can include regional adenopathy, lymphangitis, papular or pustular skin lesions, diarrhea, and hepatosplenomegaly. With septicemia, flushing, cyanosis, disseminated pustular eruption, regional lymphadenitis and cellulitis may be seen. Melioidosis pneumonia can present in many forms, but is most commonly seen as a lobar or segmental consolidation with a predilection for the upper lobes, or as multiple, widespread 0. Even with a primary pneumonic infection, dissemination (if patient survives) is likely to produce cutaneous (10-20% of cases) and internal (especially liver and spleen) abscesses even weeks to months later. Poor prognostic indicators for severe melioidosis include positive blood culture within 24 hours of incubation and neutropenia. Overall mortality (treated) for severe melioidosis is up to 50% in Thailand and 19% in Australia. Death is a rare outcome for melioidosis patients who did not have predisposing risk factors. Gram stain of lesion exudates reveals small irregularly staining, gram-negative, bacilli. The organisms can be cultured and identified from abscesses/wounds, secretions, sputum (in pneumonia), and sometimes blood and urine with standard bacteriological medium; adding 1-5% glucose, 5% glycerol, or meat infusion nutrient agar may accelerate growth. Specific, rapid immunoassays may be available in some reference laboratories for B. A single IgM titer above 1:160 with a compatible clinical picture suggests active infection; IgG is less useful in endemic regions due to high seroprevalence. In septicemic glanders, mild leukocytosis with a shift to the left or leukopenia with a relative lymphocytosis may occur. With systemic melioidosis, significant leukocytosis with left shift is common, and leucopenia / neutropenia are poor prognostic indicators; anemia, coagulopathy, and evidence of hepatic or renal dysfunction may be present. Chest radiograph in cases with pneumonia may demonstrate lobar or segmental opacification, or diffuse nodular opacities. Abdominal ultrasound should be considered on all patients with suspected glanders or melioidosis to exclude the possibility of hepatic and splenic abscesses. Prostatic abscess in melioidosis can be delineated, usually as a heterogeneous multiloculated fluid collection within an enlarged prostate, using transrectal ultrasound, or by computerized tomography or magnetic resonance imaging. Individual chronic lesions may be granulomatous and the pathologic tissue diagnosis may simulate tuberculosis, which can cause confusion in areas where both diseases are endemic (such as Thailand). Septicemic patients often require aggressive supportive care to include fluid resuscitation, vasopressors, and management of coagulopathy. Large abscesses should be drained when possible; prostatic and parotid abscesses in patients with melioidosis are unlikely to resolve without surgical intervention. The recommended therapy will vary with the type and severity of the clinical presentation. An understanding of appropriate medical management of glanders is confounded by the fact that clinical experience with this disease waned before the modern antibiotic era. Systemic melioidosis should be treated initially with ceftazidime (120 mg/kg/day intravenous in three divided doses), imipenem (60 mg/kg/day intravenous in four divided doses, max 4 g/day), or meropenem (75 mg/kg/day intravenous in three divided doses, max 6g/day). If ceftazidime or a carbapenem are not available, ampicillin/sulbactam or other intravenous beta-lactam/beta-lactamase inhibitor combinations may represent viable, albeit less-proven alternatives. Intravenous antibiotics should be continued for at least 14 days and until the patient shows clinical improvement. Patients may remain febrile for prolonged periods despite appropriate antimicrobial therapy. Median time to fever resolution is 9 days, but can be significantly longer in patients with large abscesses or empyema that are not drained. Upon completion of intravenous therapy, oral maintenance therapy (with one of the oral treatment regimens listed below) should be continued for at least 4-6 months. Oral antibiotic maintenance therapy of severe melioidosis should continue for at least 20 weeks to reduce the rate of relapse to less than 10%; however, longer courses (6-12 months) may be necessary depending upon response to therapy and severity of initial illness. Amoxicillin/clavulanic acid has been used in some areas and may be the antibiotic of choice during pregnancy or for children less than 8 years old. Combinations including fluoroquinolones show promise, but have not been validated. Standard precautions should be used to prevent personto-person transmission in proven or suspected cases. Person-to-person airborne transmission is unlikely, although secondary cases may occur through improper handling of infectious materials. Contact precautions are indicated while caring for patients with skin involvement. These animal studies indicate that ciprofloxacin may have utility as well, but it was associated with higher relapse rates than doxycycline. Optimum duration of prophylaxis is unknown, but at least 10 days and perhaps more should be attempted. Symptoms include high fever, chills, headache, malaise, followed by cough (often with hemoptysis), progressing rapidly to dyspnea, stridor, cyanosis, and death. Death results from respiratory failure, circulatory collapse, and a bleeding diathesis. Bubonic plague is characterized by swollen painful lymph nodes called buboes (often in the inguinal area), high fever, and malaise. Bubonic plague may progress spontaneously to the septicemic form (septic shock, thrombosis, disseminated intravascular coagulation) or to the pneumonic form. Diagnosis: Suspect plague if large numbers of previously healthy individuals suddenly develop severe pneumonia, especially if hemoptysis is present with gram-negative coccobacilli in sputum. Presumptive diagnosis can be made by Gram, Wright, Giemsa or Wayson stain of blood, sputum, cerebrospinal fluid, or lymph node aspirates. Treatment: Early administration of antibiotics is critical, as pneumonic plague is invariably fatal if antibiotic therapy is delayed more than 1 day after the onset of symptoms. The treatment of choice is parenteral streptomycin or gentamicin, with doxycycline or ciprofloxacin representing alternatives. Prophylaxis: For asymptomatic persons exposed to a plague aerosol or to a suspected pneumonic plague case, doxycycline 100 mg is given orally twice daily for 7 days or the duration of risk of exposure plus 1 week. The previously available licensed, killed vaccine (manufactured by Greer) was effective against bubonic plague, but not against aerosol exposure. No prophylaxis is required for asymptomatic contacts of individuals with bubonic plague. Isolation and Decontamination: Use Standard precautions for bubonic plague, and respiratory droplet precautions for suspected pneumonic plague.

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Task-related training Upper limb Pollock et al demonstrated improved upper limb function when task training was delivered at a high dose involving at least 20 hours of practice (Pollock treatment 21 hydroxylase deficiency order celexa 40 mg on-line, Farmer et al 2014) medicine overdose purchase celexa without prescription. Lower limb A Cochrane systematic review of task training for lower limb function found evidence for modest benefit in comparison with other groups (French medicine lock box discount celexa 10 mg mastercard, Thomas et al 2010) medicine 018 order celexa 20 mg fast delivery. There are also criteria for the amount of time that a limb is restricted and the exercises/activities to be carried out (Bohannan and Smith 1987; Turner-Stokes 2009b). Modifications to the original outlined programme were made to enhance compliance by reducing the amount of time the limb was restricted. Strength training A systematic review of early strength training following stroke (Ada, Dorsch et al 2006) concluded that it was effective and did not increase spasticity. Pollock et al (Pollock, Farmer et al 2014) demonstrated that strength training can improve active function and Jolk et al (Jolk, Alcantara et al 2012) concluded that 60 minutes per week of progressive strength training, or core and stability training did result in improved muscle strength with no adverse effects. Mental imagery/mental rehearsal/mirror therapy In these techniques the individual imagines their affected limb (usually upper limb) carrying out a series of movements, which may be supplemented by watching a reflection in a mirror or attempting to move the affected limb. This is hoped to initiate cortical reorganisation and enhance brain activity and fool the brain into thinking the affected limb is moving. Small studies of mirror therapy (General Medical Council 2013; Gracies 2016) and mental imagery (Esquenazi, Mayer et al 2009) provide limited evidence for improvement in active function. However, there is currently little indication of appropriate dosing regimens and carry over, and other studies have failed to show any benefit (Pandyan, Johnson et al 1999). Further research and evaluation is required before these techniques could be recommended for use in clinical practice. Electrical stimulation Electrical stimulation of muscles may be applied for reducing pain, exercise therapy or for initiation of movement in the upper and lower limb (for example functional electrical stimulation for foot drop). One systematic review concluded that electrical stimulation may be beneficial as part of a strength training programme (Glinsky, Harvey et al 2007). Pandyan et al showed that although electrical stimulation to treat spasticity in the wrist flexors did improve range of movement, the effect was not sustained post treatment (Simpson, Patel et al 2017). Further research is required to explore optimal types, intensity and duration of treatment as well as their cost benefits and utility in terms of improved quality of life. Common goal areas in the R2 High treatment of upper limb spasticity: A multicentre analysis. Clin Rehabil 2016 Direct Jun;30(6):617?22 Retrospective article reviewing five previously published research articles. P1 High Goal Attainment Scaling in the evaluation of treatment of upper limb spasticity with Direct botulinum toxin: a secondary analysis from a double-blind placebo-controlled randomized clinical trial. J Rehabil Med 2010 Jan;42(1):81?9 Goal Attainment Scaling provides a responsive measure for evaluating focal intervention for upper limb spasticity, identifying outcomes of importance to the individual/carers, which are not otherwise identifiable using standardised measures. Upper limb international spasticity P1 High study: rationale and protocol for a large, international, multicentre prospective Direct cohort study investigating management and goal attainment following treatment with botulinum toxin A in real-life clinical practice. The study reflects actual clinical practice in managing post-stroke patients upper limb spasticity management and the authors highlight the need for realistic goals and a level of competence and communication between the various members of the multidisciplinary team. Communication with patients/caregivers is vital to agree on treatment realistic goals. The authors demonstrated statistically significant benefits in active functional goals in the upper limb. Common goal areas in the treatment of upper limb spasticity: A multicentre analysis. Goal Attainment Scaling in the evaluation of treatment of upper limb spasticity with botulinum toxin: a secondary analysis from a double-blind placebo-controlled randomized clinical trial. Upper limb international spasticity study: rationale and protocol for a large, international, multicentre prospective cohort study investigating management and goal attainment following treatment with botulinum toxin A in real-life clinical practice. Serial casting S1 High versus positioning for the treatment of elbow contractures in adults with traumatic Direct brain injury: a randomized controlled trial. Effectiveness of stretch for the S1 High treatmentand prevention of contractures in people with neurological conditions: Direct a systematic review. Changes were however noted in traumatic brain injury following serial casting, but these were not sustained. Serial casting versus positioning for the treatment of elbow contractures in adults with traumatic brain injury: a randomized controlled trial. The effect of casting combined with stretching on passive ankle dorsiflexion in adults with traumatic head injuries. Accuracy of botulinum toxin type A Direct injection into the forearm muscles of chronic stroke patients with spastic flexed wrist and clenched fist: Manual needle placement evaluated using ultrasonography. Accurate manual needle placement occurred on 51% of occasions (less accurate for wrist than finger flexors). Accuracy of botulinum toxin type A injection Direct into the gastrocnemius muscle of adults with spastic equinus: Manual needle placement and electrical stimulation guidance compared using ultrasonography. Small study examining injection of gastrocnemius comparing manual needle placement with needle placement under electrical stimulation 42 participants with spasticity had needle inserted under manual placement and 39 under electrical stimulation. With manual needle placement 80% of injections were correctly sited, while 92% of injections under electrical stimulation were sited correctly. Accuracy of the ultrasonography-guided Direct injection of botulinum toxin into the tibialis posterior by using the anterior approach. Small study examining ultrasound guided needle placement into tibialis posterior, then checking accuracy with electrical stimulation in 19 participants with spasticity. Can botulinum toxin type A injection Direct technique influence the clinical outcome of patients with post-stroke upper limb spasticity? A randomized controlled trial comparing manual needle placement and ultrasound-guided injection techniques. Both groups showed improved outcomes but there were significantly better outcomes in those injected under ultrasound guidance. The efficacy of botulinum toxin injections in Direct deep muscles of upper limb with and without using needle electrical stimulation. Both groups showed improved outcomes but there were significantly better outcomes in those injected under electrical stimulation. Derived from research evidence: Research Grade: B More than one medium quality study (4-6/10) Manual needle placement appears more accurate in larger muscles such as gastrocnemius than smaller and deeper muscles. Accurate needle placement can be improved by localisation techniques and there is weak evidence that this improves outcomes. Compiled by Rhoda Allison References 1 Picelli A, Roncari L, Baldessarelli S et al Accuracy of botulinum toxin type A injection into the forearm muscles of chronic stroke patients with spastic flexed wrist and clenched fist: Manual needle placement evaluated using ultrasonography. F, Panza F et al Can botulinum toxin type A injection technique influence the clinical outcome of patients with post-stroke upper limb spasticity? The efficacy of botulinum toxin injections in deep muscles of upper limb with and without using needle electrical stimulation. Practice implications are however apparent with common practice following serial casting being the provision of a longer term orthotic combined with task-practice in some instances when appropriate. The effect of casting combined with stretching on passive ankle S1 High dorsiflexion in adults with traumatic head injuries. Effectiveness of stretch for the treatment S1 High and prevention of contractures in people with neurological conditions: a systematic Direct review. Conclusion: Regular stretch does not produce clinically important changes in joint mobility, pain, spasticity, or activity limitation in people with neurological conditions. The review again emphasises the need to evaluate more carefully when stretch intervention is applied and how this should be followed up and maintained following improvements in range of movement. Derived from research evidence: Research Grade A: >1 direct high quality studies show improvement following intervention but was not maintained once intervention ceased. Effectiveness of stretch for the treatment and prevention of contractures in people with neurological conditions: a systematic review. Direct Evidence through meta-analysis for clinical effect of task practice interventions, including constraint-induced movement therapy. Not possible with current evidence to compare different task practice interventions in the upper limb to indicate which is/are most effective. Physical rehabilitation approaches for the S1 High recovery of function and mobility following stroke. Meta-analysis evidence for practice-based interventions for physical rehabilitation in the lower limb. Optimal interventions cannot yet be identified, but reasonably robust evidence to indicate that practice produces functional improvement.

One explanation for the elevated parasite loads could be derived from the shore crabs which the eiders were apparently forced to prey upon given the scarcity of mussels medications on a plane discount 40 mg celexa fast delivery. Shore crabs harbour multiple parasites and symptoms uric acid discount celexa, therefore symptoms queasy stomach cheap celexa 10mg with visa, present higher risk of infection to eiders medications xr buy celexa 10 mg with amex. Although in this case the high parasite loads were not directly correlated with poor body condition they may have contributed as an accelerating or secondary factor. Parasitic infections may have increased energetic costs for eiders and enhanced their susceptibility to other stressors such as concurrent nutritional disease and environmental conditions. Sources: Blomert & Reinekeg 2001 and Christensen 2008 Further information and sources Blomert, A. Wyoming State-wide Bighorn/Domestic Sheep Interaction Working Group: Appendix K Disease/Stress/Predators/Research. An infected disease zone is an area or local population in which disease has been detected. Zoning may be particularly useful where disease elimination is not feasible [>Section 3. Buffers and barriers A buffer zone is an area of uninfected status (under surveillance) which surrounds the infected zone. Its purpose is to facilitate prevention of disease spread into an uninfected sub-population. The buffer zone may be identified on the basis of: an absence of hosts an absence of disease vectors only immune hosts. An effective buffer zone may take the form of a geographical, hydrological or climatic barrier. These barriers may be natural such as rivers and lakes (for terrestrial hosts) or terrestrial habitat (for aquatic hosts), or unnatural features in the landscape such as roads, fences or cleared habitat. Such barriers have been shown to be effective in control of disease by either slowing or preventing spread. Artificial barriers can also be used to inhibit movements of hosts but can themselves have adverse ecological consequences, such as the prevention of movements of wild animals caused by foot and mouth disease fences in parts of southern Africa. Specific considerations for water-borne diseases Within wetlands, zoning for the control of water-borne diseases is particularly challenging but may still be a useful approach. The simplest zone is that of an area that derives its incoming water from an unshared source and thus may continue to function independently of any infected areas. In the instance of an inland area that shares common water sources, the minimum zone would apply to the entire catchment area. Larger catchment areas may require multi-national and transboundary cooperation and jurisdictions as disease management relies on all aspects of the water catchment zone being managed accordingly. Restrictions on domestic and international trade of animals and derived products, may apply to infected zones. Continued surveillance is needed to confirm the absence of infection in uninfected areas. Movement of animals between zones Conditions applying to the movement of animals (either domestic or translocated wildlife) between zones should be comprehensively described in a zoned management strategy. Conditions should also apply to movement of other materials which could facilitate mechanical transfer. Examples of barriers and buffer zones Foot and Mouth Disease: Several countries including Botswana and Zimbabwe have implemented effective disease control strategies which include dividing the country into risk zones. These zones are managed by means of appropriate disease surveillance, movement restrictions, livestock identification and vaccination. Ring vaccination may be required as an emergency measure for animals within a certain radius of a confirmed outbreak. Anthrax: Following an outbreak in cattle a buffer zone of a specified width can be established around infected areas. All animals inside this area which have been exposed can then be vaccinated and quarantined. The influence of veterinary control fences on certain wild large mammal species in the Caprivi, Namibia. In: Conservation and Development Interventions at the Wildlife/Livestock Interface: Implications for Wildlife, Livestock and Human Health. In order to control disease spread, it is therefore crucial to understand movement patterns of potential disease hosts at a national and international level and the associated disease risks. The risk of transmission and spread of disease can be minimised by following certain guidelines for releasing and moving animals. Such measures should be supplemented by an efficient surveillance network involving the health screening of animals, particularly when they are to be moved to another area. Given the global scale of animal movements in wildlife populations and the livestock and pet trades, international cooperation in maintaining standards of moving and releasing animals is vital in preventing and controlling disease spread and reducing the risk of outbreaks. Legislation and regulations National and international legislation and regulations are in place to control the movement of animals, although disease outbreaks still occur regularly as a result of both legal and illegal movements. It is, therefore, important to familiarise yourself with legislation and regulations and their enforcing regulatory bodies, where they relate to not only a wetland site, but also to the exporting country, the transit country and the importing country [>Section 3. Certification requirements for moving animals should also be fulfilled and should clearly outline the wishes of the importing country. For this, prior consultation between veterinary authorities of importing and exporting countries may be needed. The following international organisations and regulatory bodies are concerned with the movement and trade of animals and may be able to provide further guidance. Legislation, regulations and guidance relevant to the trade and movement of domestic and wild animals (from Fevrea et al. Information should be available from government agencies, as well as other sources, to help inform the risk assessment and protocols for relocation. Thorough examination and health screening of animals prior to their relocation and routine surveillance and monitoring of animals for the early detection of disease [>Section 3. Movement restrictions for diseased/susceptible animals to prevent the spread of infection. This may include quarantine of animals before their release to ensure that they are diseasefree. Once animals have been moved to a new area, a routine standstill period may also apply, preventing the movement of certain animals on and off that site for a specified number of days [>Section 3. Methods to protect animals to be translocated from exposure to infection at their destination. Animals must be moved in a way that will not cause them injury or unnecessary suffering and additional stress that may affect their health. It is advisable not to transport animals that are considered unfit to travel, and it is illegal to do so in many countries. This includes individuals which are sick or injured, newly-born, heavily pregnant or have recently given birth. Methods for recording animal movements which will make it easier to trace and identify infected animals in the event of a disease outbreak. In some countries, it is a legal requirement that livestock keepers retain individual records and notify authorities of livestock movements, births and deaths. Government agencies may visit premises or require records be sent to them directly. In the event of a disease outbreak such as foot and mouth disease or avian influenza, movement records will inform the investigation and so it is vital they are accurate and up to date. Tools for recording animal movements may significantly improve the effectiveness of the management of disease outbreaks and food safety incidents, vaccination and animal medication programmes, animal husbandry, zoning, surveillance, early response and notification systems, animal movement controls, and animal inspection and certification. Most importantly, follow guidelines as outlined in the relevant regulations and legislation to ensure that standards for releasing and moving animals are effective and maintained. Every translocation project should be accompanied by a comprehensive disease risk analysis [>Section 3. Temporarily captive or captive-reared animals involved in conservation translocations may be particularly vulnerable to disease due to the stresses of both captivity and transport, and due to reduced genetic diversity often found in threatened species, and captive populations thereof. Thus, extra care must be taken to reduce stressors throughout any translocation [>Section 3. The range of diseases to screen for and manage will be outlined in the disease risk analysis. The soft release technique of temporarily holding released animals within a release enclosure allows a period of time in which released animals can acclimatise to the new environment and endemic diseases (to some extent), and provides a period of time, during which, veterinary intervention can be given, if necessary. The risks of disease translocation together with the logistical and administrative aspects, and potential for delays, may provide sufficient reason to attempt to rear animals in situ within natural disease range and within country of origin.