Louis Frederic Diehl, MD

• Professor of Medicine
• Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/louis-frederic-diehl-md

Each person understands and reacts to information regarding vaccines on the basis of many factors treatment mrsa purchase generic strattera pills, including past experience medicine 6 year order 40 mg strattera fast delivery, education medicine 66 296 white round pill order strattera 18mg without prescription, perception of risk of disease and vaccine offered symptoms ear infection cheap strattera 18 mg visa, perception of his or her ability to control risk, and personal values. Although parents receive information from multiple sources, they consider health care professionals their most trusted source of health information. These materials are written in understandable language and can help parents make informed decisions about immunizing their children. Other sources of objective vaccine information are available (see Internet Resources for Accurate Immunization Information, p 6) that can help health care professionals respond to questions and misconceptions about immunizations and vaccine-preventable diseases. Various approaches to informing patients and parents about the benefts and risks of disease prevention, including immunizations (see Informing Patients and Parents, p 7), and approaches to parents who refuse immunizations for their child (see Parental Refusal of Immunization, p 10) are available. That immunity is usually similar to what is acquired from natural infection, although several doses of a vaccine may have to be given for a child to develop an adequate immune response. Prior to the use of vaccinations, In the 19th and 20th centuries, some infectious diseases these diseases had begun to began to be better controlled because of improvements in decline because of improved sanitation, clean water, pasteurized milk, and pest control. However, vaccine-preventable diseases decreased dramatically after the vaccines for those diseases were licensed and were given to large numbers of children. Vaccines cause poorly understood Scientifc evidence does not support these claims. Vaccines weaken the immune Vaccinated children are not at greater risk of infection, system. Importantly, natural infections like infuenza, measles, and chickenpox do weaken the immune system, increasing the risk of other infections. Giving many vaccines at the Concomitant use studies require all new vaccines to be same time is untested. These studies are performed to ensure that new vaccines do not affect the safety or effectiveness of existing vaccines given at the same time and that existing vaccines administered at the same time do not affect the safety or effectiveness of new vaccines. Vaccines can be delayed, Many vaccine-preventable diseases occur in early infancy. Any delay in receiving age-appropriate immunization would increase the risk and severity of diseases that vaccines are administered to prevent. These educational materials build on the latest research in vaccine and communication science and are designed to help health care professionals remain current on vaccine topics; strengthen communication and trust between health care professionals and parents; and share up-to-date, easy-to-use information about vaccines and vaccine-preventable diseases with parents. Fact sheets are available in English and Spanish and are written for a variety of reading levels, and many include stories of families whose children have experienced a vaccinepreventable disease. People can download these materials and enroll for e-mail updates when new resources are posted at Passive Immunization Passive immunization entails administration of preformed antibody to a recipient and, unlike active immunization, achieves protection for only a short period of time. The choice is dictated by the types of products available, the type of antibody desired, the route of administration, timing, and other considerations. Immune Globulin Subcutaneous (Human) has been approved for treatment of patients with primary immune defciency states. Whole blood and blood components also are batch tested for West Nile virus; during an outbreak in a particular geographic area, units may be tested by individual unit nucleic acid amplifcation testing (see Blood Safety, p 114; and West Nile Virus, p 792). Many donors (1000 to 60 000 donors per lot of fnal product) are used to include a broad spectrum of antibodies. Health care professionals should refer to the package insert for total maximal dose at one time. The usual dose (limited by muscle mass and the volume that should be administered) is 100 mg/kg (equivalent to 0. These reactions include systemic symptoms such as chills, fever, and shock-like symptoms. Because these reactions are rare, routine screening for IgA defciency is not recommended. Specifc Immune Globulins Specifc immune globulins differ from other preparations in selection of donors and may differ in number of donors whose plasma is included in the pool from which the product is prepared. Specifc human plasma-derived immune globulins are prepared by the same types of procedure as other immune globulin preparations. Recommendations for use of these immune globulins are provided in the discussions of specifc diseases in Section 3. An intramuscularly administered humanized mouse monoclonal antibody preparation (palivizumab) for prevention of respiratory syncytial virus is available. Various methods are used by different manufacturers to prepare a product for intravenous use. Antibody concentrations against other pathogens, such as Streptococcus pneumoniae, vary widely among products and even among lots from the same manufacturer. Maintenance of a trough IgG concentration of at least 500 mg/dL (5 g/L) has been demonstrated to correlate with clinical response, but individual patient dosing should be optimized to decrease the frequency of serious infections. Studies in children with agammaglobulinemia suggest that IgG trough concentrations maintained at greater than 800 mg/dL prevented serious bacterial illnesses and enteroviral meningoencephalitis. Dosage and frequency of infusions should be based on clinical effectiveness in an individual patient and in conjunction with an expert on primary immune defciency disorders. Therapy appears most likely to be benefcial when used early in the course of illness. All products currently available in the United States are believed to be free of known pathogens. These reactions may result from formation of IgG aggregates during manufacture or storage. There may be product-to-product variations in adverse effects among individual patients. Less common but severe reactions include hypersensitivity and anaphylactoid reactions marked by fushing, changes in blood pressure, and tachycardia; thrombotic events; aseptic meningitis; noncardiogenic pulmonary edema; and renal insuffciency and failure. Renal failure occurs mainly in patients with preexisting renal dysfunction receiving sucrose-containing products and, in such cases, likely is attributable to sucrose-mediated acute tubular necrosis. Many thrombotic adverse events could be linked to presence of trace amounts of clotting factors that copurify with IgG and occur more commonly (but not exclusively) in patients with risk factors for thrombosis. Determining the precise cause and how to prevent thrombotic complications is an area of active investigation. Anaphylactic reactions induced by anti-IgA can occur in patients with primary immune defciency who have a total absence of circulating IgA and develop IgG antibodies to IgA. These reactions are rare in patients with panhypogammaglobulinemia and potentially are more common in patients with selective IgA defciency and subclass IgG defciencies. Because of the extreme rarity of these reactions, however, screening for IgA defciency and anti-IgA antibodies is not recommended routinely. Smaller doses, administered more frequently (ie, weekly), result in less fuctuation of serum IgG concentrations over time. Antibodies of Animal Origin (Animal Antisera) Products of animal origin used for neutralization of toxins or prophylaxis of infectious diseases are derived from serum of horses or sheep immunized with the agent/toxoid of interest. These products are derived by concentrating the serum globulin fraction with ammonium sulfate.

Responding to immunotherapy If ultrasound imaging shows a tumor has responded symptoms zinc deficiency adults discount strattera 10mg with amex, the However symptoms 6 year molars purchase genuine strattera, the analysis of her tumor suggested she might patient continues with chemotherapy until surgery medicine evolution 18mg strattera mastercard. She took the opportunity to researchers are able to study the tumor and learn why it participate in a trial combining chemotherapy with an immune responded medicine 2020 purchase cheap strattera on-line. Lawrence agreed, though she admits to having doubts about venturing far from home. The study found that more than half of the 20 women in drug shrank tumors in all 13 patients enrolled in the pilot study, the study who took the drug once daily prior to surgery had anywhere from 30 to 98 percent, with a median reduction of no evidence of disease at the time of surgery. Instead, the trial paved the way for the Food and Drug AdministraI went on with my everyday life. He has all the symptoms of prostate cancer, but every doctor he has called delivers the same message. One woman wrote in include a win-win research collaboration do something about them. My husband takes care of me every day vivorship within traditionally underserved From her office in Pickens Academic how can I tell him how bad I feel to burden populations. Lu, for providing organizations to provide them with hands-on Hispanic community, Larkin Strong, Ph. McNeill also points to a correlation with health insurance get pap smears, McNeill the department still has much work to between poverty and obesity. When Atkins was in sixth grade science class when her teacher Program director Shaun Caldwell and old enough to vent, her principal told her threatened to cut all her lab describes Atkins as a star. And she has such learned will be helpful when she graduates giving an assistant step-by-step instructions. There were the occasional aides who a church ceremony, a big party and, eventually, Advocacy. Sharma and the Nobel Prize-winning Allison have collaborated on combination immunotherapy research for the treatment of several cancers. She created the gnotobiotic a better understanding of how the drugs that work in understanding factors that enhance housing area for investigators to promote the are developed work and who will benefit most and hinder cancer immunotherapy. In addition to her work in the lab, Spencer has volunteered as a patient advocate in the Stem Cell Transplant Unit for the past six years. One category of immune checkcompared to 16 months each for the other One Phase I clinical trial underway at point blockade drugs blocks activatwo groups. She spent most of her their way through a mini-Olympic obstacle she rang the bell symboltime creating ladybugand rainbow-themed course. University of Houston Cougar basketball that develops in the pineal gland deep within But when Lauryn became involved in the team member. This requires taking an active role in ensuring we do all we can each and every day to take care of our present and future selves. That includes avoiding high-risk behavior, making healthy lifestyle choices that can help prevent many cancers and undergoing recommended screenings that can detect the disease early on. This powerful knowledge can lead to regular checkups to catch cancer sooner and increase the chances of survival. The final 5 percent are inherited Certain factors make it more likely that tested for a hereditary when a faulty gene is passed from generation cancers in a family are caused by an inherited cancer mutation to generation. Doctors may encourage these people to the program, one of the largest of its kind get tested, she says. Gynecologic Cancer Genetics Clinic Offers genetic counseling and testing to women who have ovarian or endometrial (uterine) cancer and to women who have never had ovarian or endometrial cancer but have a significant family history of the disease. If the test uncovered the genetic mutation 1 percent of all pancreatic cancer patients. It was aggressive, that caused her cancer, Lippman then could be matched with doctors said, and it had spread to her liver. The discovery meant she could stop chemo and enroll in a clinical trial at same part of the body.

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Infected people also may pass adult worms from the rectum medicine ethics generic strattera 25 mg mastercard, from the nose after migration through the nares treatment vitiligo 25mg strattera with amex, and from the mouth x medications buy strattera 18 mg online, usually in vomitus treatment narcolepsy order strattera 25 mg mastercard. Adult worms may be detected by computed tomographic scan of the abdomen or by ultrasonographic examination of the biliary tree. Nitazoxanide taken twice a day for 3 days also is effective against A lumbricoides. Although widely accepted for treatment of ascariasis, albendazole is not labeled for this indication. Likewise, ivermectin and nitazoxanide are not labeled for use for treatment of ascariasis. The safety of ivermectin in children weighing less than 15 kg and in pregnant women has not been established. In 1-year-old children, the World Health Organization recommends reducing the albendazole dose to half of that given to older children and adults. Reexamination of stool specimens 2 weeks after therapy to determine whether the worms have been eliminated is helpful for assessing therapy. Conservative management of small bowel obstruction, including nasogastric suction and intravenous fuids, may result in resolution of major symptoms before administration of anthelmintic therapy. Piperazine, which is not available in the United States, causes worms to be paralyzed, allows them to be eliminated in stool, and may relieve intestinal obstruction caused by heavy worm burden. Surgical intervention occasionally is necessary to relieve intestinal or biliary tract obstruction or for volvulus or peritonitis secondary to perforation. Endoscopic retrograde cholangiopancreatography has been used successfully for extraction of worms from the biliary tree. Vegetables cultivated in areas where uncomposted human feces are used as fertilizer must be thoroughly cooked before eating. Periodic mass treatment of preschooland school-aged children in areas where ascariasis is endemic can reduce the prevalence and intensity of infection of Ascaris lumbricoides as well as of other soil-transmitted helminths. Children at highest risk include children with new-onset or a relapse of hematologic malignancy and allogeneic hematopoietic stem cell transplant recipients. Invasive infection usually involves pulmonary, sinus, cerebral, or cutaneous sites. Rarely, endocarditis, osteomyelitis, meningitis, infection of the eye or orbit, and esophagitis occur. The hallmark of invasive aspergillosis is angioinvasion with resulting thrombosis, dissemination to other organs, and occasionally, erosion of the blood vessel wall with catastrophic hemorrhage. Aspergillosis in patients with chronic granulomatous disease rarely displays angioinvasion. Patients with otomycosis have chronic otitis media with colonization of the external auditory canal by a fungal mat that produces a dark discharge. This form of aspergillosis occurs most commonly in immunocompetent children with asthma or cystic fbrosis and can be a trigger for asthmatic fares. Allergic sinusitis occurs in children with nasal polyps or previous episodes of sinusitis or children who have undergone sinus surgery. Allergic sinusitis is characterized by symptoms of chronic sinusitis with dark plugs of nasal discharge. Aspergillus fumigatus is the most common cause of invasive aspergillosis, with Aspergillus favus being the next most common. Several other species, including Aspergillus terreus, Aspergillus nidulans, and Aspergillus niger, also cause invasive human infections. Incidence of disease in transplant recipients is highest during periods of neutropenia or during treatment for graft-versus-host disease. Health care-associated outbreaks of invasive pulmonary aspergillosis in susceptible hosts have occurred in which the probable source of the fungus was a nearby construction site or faulty ventilation system. The organism usually is not recoverable from blood (except A terreus) but is isolated readily from lung, sinus, and skin biopsy specimens when cultured on Sabouraud dextrose agar or brain-heart infusion media (without cycloheximide). Aspergillus species can be a laboratory contaminant, but when evaluating results from ill, immunocompromised patients, recovery of this organism frequently indicates infection. Biopsy of a lesion usually is required to confrm the diagnosis, and care should be taken to distinguish aspergillosis from zygomycosis, which appears similar by diagnostic imaging studies. An enzyme immunosorbent assay serologic test for detection of galactomannan, a molecule found in the cell wall of Aspergillus species, is available commercially and has been found to be useful in children and adults. A negative galactomannan test result does not exclude diagnosis of invasive asper gillosis. False-negative galactomannan test results consistently occur in patients with chronic granulomatous disease, so the test should not be used in these patients. Limited data suggest that other biomarkers, including 1,3-fi-D glucan testing may be useful in the diagnosis of aspergillosis. Unlike adults, children frequently do not manifest cavitation or the air crescent or halo signs on chest radiography, and lack of these characteristic signs does not exclude the diagnosis of invasive aspergillosis. In allergic aspergillosis, diagnosis is suggested by a typical clinical syndrome with elevated total concentrations of immunoglobulin (Ig) E (fi1000 ng/mL) and Aspergillus-specifc serum IgE, eosinophilia, and a positive result from a skin test for Aspergillus antigens. In people with cystic fbrosis, the diagnosis is more diffcult, because wheezing, eosinophilia, and a positive skin test result not associated with allergic bronchopulmonary aspergillosis often are present. Voriconazole has been shown to be superior to amphotericin B in a large, randomized trial in adults. Therapy is continued for at least 12 weeks, but treatment duration should be individualized. Monitoring of serum galactomannan serum concentrations twice weekly may be useful to assess response to therapy concomitant with clinical and radiologic evaluation. Voriconazole is metabolized in a linear fashion in children (nonlinear in adults), so the recommended adult dosing is too low for children. Posaconazole has been used as salvage therapy in adults with invasive aspergillosis. Pharmacokinetics and safety of posaconazole have not been evaluated in younger children. Caspofungin has been studied in pediatric patients older than 3 months of age as salvage therapy for invasive aspergillosis. The pharmacokinetics of caspofungin in adults differ from those in children, in whom a body-surface area dosing scheme is preferred to a weight-based dosing regimen. Itraconazole alone is an alternative for mild to moderate cases of aspergillosis, although extensive drug interactions and poor absorption (capsular form) limit the utility of itraconazole. Lipid formulations of amphotericin B can be considered, but A terreus is resistant to all amphotericin B products. Data are limited on the safety and effcacy of voriconazole, itraconazole, posaconazole, and caspofungin in children. The effcacy and safety of combination antifungal therapy for invasive aspergillosis in children have not been evaluated adequately. Decreasing immunosuppression, if possible, specifcally decreasing corticosteroid dose, is important to disease control. Surgical excision of a localized invasive lesion (eg, cutaneous eschars, a single pulmonary lesion, sinus debris, accessible cerebral lesions) usually is warranted. In pulmonary disease, surgery is indicated only when a mass is impinging on a great vessel. Allergic bronchopulmonary aspergillosis is treated with corticosteroids and adjunctive antifungal therapy is recommended. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Environmental measures reported to be effective include erecting suitable barriers between patient care areas and construction sites, routine cleaning of air-handling systems, repair of faulty air fow, and replacement of contaminated air flters. Higheffciency particulate air flters and laminar fow rooms markedly decrease the risk of exposure to conidia in patient care areas. Posaconazole has been shown to be effective in 2 randomized controlled trials as prophylaxis against invasive aspergillosis for patients 13 years of age and older who have undergone hematopoietic stem cell transplantation and have graft-versus-host disease and in patients with hematologic malignancies with prolonged neutropenia. Low-dose amphotericin B, itraconazole, voriconazole, or posaconazole prophylaxis has been reported for other high-risk patients, but controlled trials have not been completed in pediatric patients.

Randomized clinical trials have demonstrated that infant prophylaxis with daily nevirapine or nevirapine/zidovudine during breastfeeding signifcantly decreases the risk of postnatal transmission via human milk treatment tinea versicolor trusted strattera 18 mg. Available data indicate that vari-1 ous antiretroviral drugs have differential penetration into human milk; some antiretroviral drugs have concentrations in human milk that are much higher than concentrations in maternal plasma medicine jewelry generic 40 mg strattera, and other drugs have concentrations in human milk that are much lower than concentrations in plasma or are not detectable symptoms 0f ovarian cancer order strattera 18mg line. This raises potential concerns regarding infant toxicity as well as the potential for selection of antiretroviral-resistant virus within human milk 7 medications that cause incontinence purchase strattera 18mg mastercard. In areas where infectious diseases and malnutrition are important causes of infant mortality and where safe, affordable, and sustainable replacement feeding may not be available, infant feeding decisions are more complex. Although apparent maternal-infant transmission has been reported, the rate and timing of transmission have not been established. Transmission may be reduced with hand hygiene and covering of lesions with which the infant might come into contact. Women with herpetic lesions on a breast or nipple should refrain from breastfeeding an infant from the affected breast until lesions have resolved but may breastfeed from the unaffected breast when lesions on the affected breast are covered completely to avoid transmission. However, the presence of rubella virus in human milk has not been associated with significant disease in infants, and transmission is more likely to occur via other routes. Women with rubella or women who have been immunized recently with live-attenuated rubella virus vaccine may continue to breastfeed. Secretion of varicella vaccine virus and infection of a breastfeeding infant of a mother who received varicella vaccine has not been noted in the few instances where it has been studied. Varicella vaccine may be considered for a susceptible breastfeeding mother if the risk of exposure to natural varicella-zoster virus is high. Recommendations for use of passive immunization and varicella vaccine for breastfeeding mothers who have had contact with people in whom varicella has developed or for contacts of a breastfeeding mother in whom varicella has developed are available (see Varicella-Zoster Infections, p 774). Animal experiments have shown that West Nile virus can be transmitted in animal milk, and other related faviviruses can be transmitted to humans via unpasteurized milk from ruminants. The degree to which West Nile virus is transmitted in human milk and the extent to which breastfeeding infants become infected are unknown. Because the health benefts of breastfeeding have been established and the risk of West Nile virus transmission through breastfeeding is unknown, women who reside in an area with endemic West Nile virus infection should continue to breastfeed. The potential for transmission of infectious agents through donor human milk requires appropriate selection and screening of donors and careful collection, processing, and storage of milk. These policies require documentation, counseling, and observation of the affected infant for signs of infection and potential testing of the source mother for infections that could be transmitted via human milk. Recommendations for management of a situation involving an accidental exposure may be found at Discuss inadvertent administration of the donor milk with the parent(s) of the recipient infant. Collection of milk from the birth mother of a preterm infant does not require processing if fed to her infant, but proper collection and storage procedures should be followed. Microbiologic quality standards for fresh, unpasteurized, expressed milk are not available. The presence of gramnegative bacteria, S aureus, or alphaor beta-hemolytic streptococci may preclude use of expressed human milk. Routine culture of milk that a birth mother provides to her own infant is not warranted. Although these drugs may appear in milk, the potential risk to an infant must be weighed against the known benefts of continued breastfeeding. As a general guideline, an antimicrobial agent is safe to administer to a lactating woman if it is safe to administer to an infant. Only in rare cases will interruption of breastfeeding be necessary because of maternal medications. The amount of drug an infant receives from a lactating mother depends on a number of factors, including maternal dose, frequency and duration of administration, absorption, timing of medication administration and breastfeeding, and distribution characteristics of the drug. When a lactating woman receives appropriate doses of an antimicrobial agent, the concentration of the compound in her milk usually is less than the equivalent of a therapeutic dose for the infant. A breastfed infant who requires antimicrobial therapy should receive the recommended doses, independent of administration of the agent to the mother. Current information about drugs and lactation can be found at the Toxicology Data Network Web site ( Data for drugs, including antimicrobial agents, administered to lactating women are provided in several categories, including maternal and infant drug levels, effects in breastfed infants, possible effects on lactation, the category into which the drug has been placed by the American Academy of Pediatrics, alternative drugs to consider, and references. Prevention and control of infection in out-of-home child care settings is infuenced by several factors, including the following: (1) health status, practice of personal hygiene, and immunization status of care providers; (2) environmental sanitation; (3) food-handling procedures; (4) age and immunization status of children; (5) ratio of children to care providers; (6) physical space and quality of facilities; (7) frequency of use of antimicrobial agents in children in child care; and (8) adherence to standard precautions for infection control. Adequately addressing problems of infection control in child care settings requires collaborative efforts of public health offcials, licensing agencies, child care providers, physicians, nurses, parents, employers, and other members of the community. Child care programs should require that all enrollees and staff members receive ageappropriate immunizations and routine health care. In addition, these programs have the opportunity to provide parents with ongoing instruction in child development, hygiene, appropriate nutrition, and management of minor illnesses. Many early education and child care programs have access to health consultants who can assist providers and parents with these issues ( Classifcation of Care Service Child care services commonly are classifed by the type of setting, number of children in care, and age and health status of the children. Small family child care homes provide care and education for up to 6 children simultaneously, including any preschoolaged relatives of the care provider, in a residence that usually is the home of the care provider. Large family child care homes provide care and education for between 7 and 12 children at a time, including any preschool-aged relatives of the care provider, in a residence that usually is the home of one of the care providers. A child care center is a facility that provides care and education to any number of children in a nonresidential setting or to 13 or more children in any setting if the facility is open on a regular basis. A facility for ill children provides care for 1 or more children who are excluded temporarily from their regular child care setting for health reasons. A facility for children with special needs provides specialized care and education for 1 child or more who cannot be accommodated in a setting with typically developing children. All 50 states regulate outof-home child care; however, regulation enforcement is directed toward center-based child care; few states or municipalities license or enforce regulations as carefully for small or large child care homes. Regulatory requirements for every state can be accessed through the Web site of the National Resource Center for Health and Safety in Child Care and Early Education ( Grouping of children by age varies, but in child care centers, common groups consist of infants (birth through 12 months of age), toddlers (13 through 35 months of age), preschoolers (36 through 59 months of age), and school-aged children (5 through 12 years of age). Infants and toddlers who require diapering or assistance in using a toilet have signifcant hands-on contact with care providers. Furthermore, they have oral contact with the environment, have poor control over their secretions and excretions, and have immunity to fewer common pathogens. Toddlers also have frequent direct contact with each other and with secretions of other toddlers. Therefore, child care programs that provide infant and toddler care should be vigilant about practice of infection-control measures. Management and Prevention of Illness Modes of transmission of bacteria, viruses, parasites, and fungi within child care settings are listed in Table 2. In most instances, the risk of introducing an infectious agent into a child care group is related directly to prevalence of the agent in the population and to the number of susceptible children in that group. Transmission of an agent within the group depends on the following: (1) characteristics of the organism, such as mode of spread, infective dose, and survival in the environment; (2) frequency of asymptomatic infection or carrier state; and (3) immunity to the respective pathogen. Transmission also can be affected by behaviors of the child care providers, particularly hygienic 1 American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care. Children infected in a child care group can transmit organisms not only within the group but also within their households and the community. Appropriate hand hygiene and adherence to immunization recommendations are the most important factors for decreasing transmission of disease in child care settings. Options for management of ill or infected children in child care and for reducing transmission of pathogens include the following: (1) antimicrobial treatment or prophylaxis when appropriate; (2) immunization when appropriate; (3) exclusion of ill or infected children from the facility when appropriate; (4) provision of alternative care at a separate site; (5) cohorting to provide care (eg, segregation of infected children in a group with separate staff and facilities); (6) limiting new admissions; (7) hand hygiene; and (8) closing the facility (a rarely exercised option). Recommendations for controlling spread of specifc infectious agents differ according to the epidemiology of the pathogen (see disease-specifc chapters in Section 3) and characteristics of the setting. Infection-control procedures in child care programs that decrease acquisition and transmission of communicable diseases include: (1) periodic (at least annual) review of facility-maintained child and employee illness records, including current immunization status; (2) hygienic and sanitary procedures for toilet use, toilet training, and diaper changing; (3) review and enforcement of hand-hygiene procedures; (4) environmental sanitation; (5) personal hygiene for children and staff; (6) sanitary preparation and handling of food; (7) communicable disease surveillance and reporting; and (8) appropriate handling of animals in the facility. Policies that include education and implementation of procedures for fulland part-time employees and volunteers as well as exclusion policies aid in control of infectious diseases.