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This refers to disease markers that ought to cause changes in the disease process 100 mg viagra sublingual for sale. Studies of heart-attack patients done in the 1960s showed that some died suddenly from irregular heart rhythms cheap viagra sublingual online master card. Physicians thought this would reduce deaths in all patients with heart attacks cheap viagra sublingual online mastercard, but a large study found that the death rate actually increased when all patients were given these drugs. However, it may be considered when deciding if the study was carried out for a sufficient amount of time. It has been only slightly more than 50 years since statistics was first felt to be an important part of the medical curriculum. In a 1947 commentary in the British Medical Journal entitled “Statistics in the medical curriculum? We recognize the need for physicians to be able to understand the nature of statistical processes and to be able to interpret these for their patients. The science is in the medical literature and in the ability of the clinician to interpret that literature. Students learn the clinical and basic sciences that are the foundation of medicine during the first 2 years of medical school. The art of medicine is in determining to which patients the literature will apply and then communicating the results to the patients. Students learn to perform an adequate history and physical examination of patients to extract the maximum amount of evidence to use for good medical decision making. Students must also learn to give patients information about their illnesses and empower them to act appropriately to effect a cure or control and moderate the illness. Finally, as pracitioners, physicians must be able to know when to apply the results of the most current literature to patients, and when other approaches should be used for their patients. Evidence- based medicine can be viewed as an attempt to standardize the practice of medicine, but at the same time, it is not “cookbook” medicine. However, it is still up to the clinician to determine whether the individual patient will benefit from that approach. If your patient is very different from those for whom there is evidence, you may be justified in taking another approach to solve the prob- lem. These decisions ought to be based upon sound clinical evidence, scientific knowledge, and pathophysiological information. Evidence-based medicine is not a way for managed care (or anyone else) to simply save money. Evidence- based practices can be more or less expensive than current practices, but they should be better. Evidence-based medicine is the application of good science to the practice of health care, leading to reproducibility and transparency in the science support- ing health-care practice. Evidence-based medicine is the way to maximize the benefits of science in the practice of health care. Lord Kelvin, President of the Royal Society, 1895 Learning objectives In this chapter you will learn: r cause-and-effect relationships r Koch’s principles r the concept of contributory cause r the relationship of the clinical question to the type of study The ultimate goal of medical research is to increase our knowledge about the interaction between a particular agent (cause) and the health or disease in our patient (effect). Causation is the relationship between an exposure or cause and an outcome or effect such that the exposure resulted in the outcome. However, a strong association between an exposure and outcome may not be equivalent to proving a cause-and-effect relationship. By the end of this chapter, you will be able to determine the type of causation in a study. Cause-and-effect relationships Most biomedical research studies try to prove a relationship between a partic- ular cause and a specified effect. The cause may be a risk factor resulting in a disease, an exposure, a diagnostic test, or a treatment helping alleviate suffer- ing. The stronger the design of a study, the more likely it is to prove a relationship between cause and effect. Not all study designs are capable of proving a cause-and-effect relation- ship, and these study designs will be discussed in a later chapter. In some studies relating to the prognosis of disease, time is the independent variable. It can be an outcome such as death or survival, the degree of improvement on a clinical score or the detection of disease by a diagnostic test. You ought to be able to identify the cause and effect easily in the study you are evaluating if the structure of the study is of good quality. Types of causation It’s not always easy to establish a link between a disease and its suspected cause. For example, we think that hyperlipidemia (elevated levels of lipids or fats in the blood) is a cause of cardiovascular disease. Perhaps hyperlipidemia is caused by inac- tivity or a sedentary lifestyle and the lack of exercise actually causes both cardio- vascular disease and hyperlipidemia. Streptococcus viridans is a bac- terium that can cause infection of the heart valves. However, it takes more than the presence of the bacterium in the blood to cause the infection. We cannot say that the presence of the bacterium in the blood is sufficient to cause this infection. There must be other factors such as local deformity of the valve or immunocompromise that make the valve prone to infection. In a more mundane example, it has been noted that the more churches a town has, the more robberies occur. No – it simply means that a third variable, population, explains the number both of churches and of muggings. Likewise, we know that Streptococcus viridans is a cause of subacute endocarditis. But it is neither the only cause, nor does it always lead to the result of an infected heart valve. In medical science, there are two types of cause-and-effect relationships: Koch’s postulates and contributory cause. Robert Koch, a nineteenth-century microbiologist, developed his famous postulates as criteria to determine if a cer- tain microbiologic agent was the cause of an illness. Acute infectious diseases were the scourge of mankind before the mid twentieth century. As a result of bet- ter public health measures such as water treatment and sewage disposal, and antibiotics, these are less of a problem today. He created the following postulates in an attempt to determine the relationship between the agent causing the illness and the illness itself. Second, when found it must be able to be isolated from the diseased host and grown in a pure culture. Next, the agent from the culture when introduced into a healthy host must cause the illness. Finally, the infectious agent must again be recovered from the new host and grown in a pure culture. While this model may work well in the study of acute infectious diseases, most modern illnesses are chronic and degenerative in nature.

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As with the previous section buy discount viagra sublingual 100mg, it is important to note that the following information is aimed at an adult audience in order to build their capacity to engage with young people in drugs education and prevention work in the school setting and purchase 100mg viagra sublingual with mastercard, as such generic 100mg viagra sublingual amex, is not a resource to be given out to students in an unmediated fashion. Engaging young people in discussion around drug facts should always be done in a way which is (i) developmentally appropriate (ii) in accordance with the curriculum being used (iii) in accordance with the school’s substance policy The information is organised around the following headings: y Name y Physical Description(s) y Administration y Desired Effects y Duration of Effects y Signs and Symptoms of Use y Short Term Risks y Long Terms Risks y Legal Status 25 Drug Facts All drugs are viewed in terms of both their desired effects and their associated short and long-term risks. This emphasis on risk, as opposed to distinctions between so called ‘soft’ and ‘hard’ drugs is because the risks involved in drug use are not located purely within the drug itself but rather, how the drug is used, how much is used, who uses it and where – as discussed earlier in the section on the epidemiological triangle. Equally, the soft/hard distinction can also be used to build an argument as to which drugs (i. Drugs and the Law Drug laws in Ireland are complex and subject to change and schools are advised to be proactive in developing a good working relationship with local Gardaí as they will be able to clarify issues relating to drug laws. The laws that are the most relevant to the school setting include the Misuse of Drugs Acts 1977 and 1984. Offences under the Misuse of Drugs Act include: y Possession of any small amount for personal use y Possession with intent to supply to another person y Production y Supplying or intent to supply to another person y Importation or Exportation y Allowing premises you occupy to be used for the supply or production of drugs or permitting the use of drugs on premises y Growing of opium poppies, cannabis and coca plants y The printing or sale of books or magazines that encourage the use of controlled drugs or which contain advertisements for drug equipment There are other laws controlling tobacco, alcohol, solvents and medicines. Equally, drugs, their various uses and our understanding of them change over tim e. W ith this in m ind, there is a list of organisations and websites at the end of this handbook which you can consult if you encounter substances or related behaviours not included in the following section. Tobacco use also figures in cannabis smoking, where cannabis users may use tobacco along with the crumbled cannabis resin in the production of a joint or spliff (hand-rolled cannabis cigarette). Tobacco can also be administered via smokeless products such as snuff, which is sniffed, or ‘dipped’ that is, held between the lip and the gum of the mouth. Under Section 6 of the Tobacco (Health Promotion and Protection) Act 1988 the importation and distribution of these smokeless products are banned due to concerns around their adverse effects on health. However, the acute effects of nicotine dissipate within a few minutes and nicotine disappears from the body in a few hours, as it is metabolised fairly rapidly. It is the combination of the mode of administration (smoking) and nicotine’s highly addictive properties (the W orld Health Organisation ranks nicotine as being more addictive than heroin, cocaine, alcohol, cannabis and caffeine18) which impact on the number of dependent users. By inhaling, the smoker can get nicotine to the brain very rapidly with every puff. A typical smoker will take 10 puffs on a cigarette over a period of five minutes that the cigarette is lit. Thus, a person who smokes about one and a half packs (30 cigarettes) daily gets 300 ‘hits’ of nicotine to the brain each day. W ithin eight hours of stopping, oxygen in the blood increases to norm al levels and carbon m onoxide levels in the blood drop to norm al. Twenty-four hours after stopping, the risk of sudden heart attack decreases and by 48 hours, one’s sense of taste and sm ell begin to return to norm al. Long-term use will result in a staining of the teeth and possibly of the fingers and nails. Short Term Risks Although nicotine is highly toxic (like cyanide, if a sufficient amount is ingested, death can result in a few minutes from respiratory failure caused by paralysis23) there is a tendency to associate the health risks related to sm oking with long-term use. However, outside of the im m ediate im pact sm oking m ay have on a young person in term s of the sm ell of tobacco and the cost, there are short-term adverse health effects: y Increased risk of dependence – those who start smoking regularly when young tend to carry on smoking throughout their adult life, most … adults who smoke began during adolescence. Outside of these short-term health risks, adolescent tobacco use is “… often the first drug used by young people who use alcohol, marijuana and other drugs. Because your lungs You get bad breath grow at a slower rate and are three times and don’t work as more likely to be well, less oxygen gets out of breath than to your muscles. Your hands smell Your heart has to of stale cigarette work harder, it will smoke and your beat two to three fingers and nails times faster than can become stained someone who yellow. Throat Cancer, Stomach Cancer, Heart Disease and Bronchitis Long Terms Risks The increased risk of lung cancer is the risk predominantly associated with smoking. However, long-term exposure to nicotine increases the risk of: y Heart disease y Heart attack y Blood clots y Strokes y Bad circulation y Ulcers y Lung infection y Bronchitis y Emphysema y Cancers of the mouth and throat29 30 Drug Facts Equally, smoking impacts on both male and female fertility – decreased fertility is associated with women who smoke and wish to start a family and the risk of impotence is 50% higher in male smokers than in non-smokers. There is evidence of an increased risk of a prem ature birth, stillbirth and early death of the newborn baby where the m other sm okes m ore than five cigarettes a day and infants born to m others who sm oked throughout pregnancy also have a lower birth weight. For children, this increases the risks of asthm a and other respiratory illnesses and ‘glue’ or m iddle ear disease. Legal Status Health Act 2001 prohibits the sale of tobacco to young people under the age of eighteen years. Harm Reduction Approaches There are no ‘safe or safer’ tobacco products and given the adverse health effects of any tobacco product non-smoking is the only safer option. However, this over familiarity with alcohol poses in itself an enormous challenge for the promotion of healthier life-styles. Given the prevalence of alcohol use in Ireland, “83% of men and 74% of women reported alcohol consumption in the last month (and) … 40% of school-going young people reported never having had an alcoholic drink Alcoholic drinks can be divided into six different categories: beers, cider, table wines, fortified wines, distilled spirits and liqueurs. Ethanol is produced as a result of the ferm entation by yeasts of sugars from fruits, vegetables or grain34 and it is the difference in production m ethods and ingredients which brings about the different tastes and strengths. For exam ple, beer is produced by the ferm entation of brewer’s wort, with hops added for flavour. This results in an alcoholic drink which is approxim ately five parts ethanol to 100 parts water; as opposed to whiskey which is produced by the distillation of ferm ented barley, rye or corn m ash, which can contain as m uch as 50% ethanol. The following table35 presents the six different categories of drink, the types within each category, their alcohol content and exam ples of “standard drink” equivalents for each type. A standard drink equals 10gm s of pure alcohol and is the m easure sim ilar to “units” which is now used in the Royal College of Psychiatrists’ guidelines to sensible drinking. The upper recom m ended lim it per week is 21 standard drinks for adult m ales and 14 standard drinks for adult fem ales. Stage of Intoxication Impact 1st Stage: Happy Talkative, sociable, relaxed, less inhibited and worried, some loss of judgement 2nd Stage Excited Emotional, erratic behaviour, impaired thinking, slower reactions slower, poor judgement, loss of control over actions, driving impaired 3rd Stage Confused Staggering, disoriented, moody, exaggerated emotional reactions (fear, anger), slurred speech, double vision 4th Stage In a Stupor Unable to stand or walk, vomiting, approaching paralysis, barely conscious, apathetic and inert 5th Stage In a Coma Completely unconscious, few or no reflexes, may end in death from respiratory paralysis The effects described above are variable and dependant on a number of different factors. Factors Impacting on the Mood Altering Effects of Alcohol Type of drink y alcohol content y carbonated or effervescent alcoholic drinks are absorbed faster How quickly it is drunk y it takes approximately an hour for the alcohol in a standard drink to be broken down by the liver. If alcohol is consumed at a faster rate than it can be broken down, alcohol remains in the bloodstream and blood alcohol concentration rises When food was last eaten y approximately 90% of the alcohol drunk is absorbed by the small intestine and the amount and type of food in the stomach will impact on the rate of absorption. If alcohol is drunk quickly, this leads to a greater concentration of alcohol in the bloodstream the surroundings y the environment in which the alcohol is consumed can contribute to the effects and of the drinker y amount of alcohol drunk in terms of the social norms and controls at play in any given situation. This is the only way to sober up; approaches such as drinking black coffee, getting fresh air, taking cold showers or getting sick (in the mistaken belief that it will clear the stomach of alcohol) have no effect on a drinker’s blood alcohol level. Short Term Risks Childhood and adolescence are periods of growth and development and, as with all drugs, this makes young people particularly vulnerable to adverse short-term effects arising from alcohol use. The combination of physical immaturity and the ongoing development and refinement of values and attitudes, choice and decision making skills, personal and social skills. Other sedative drugs would include: y Solvents y Allergy medicines y Cough and cold medicines y Benzodiazepines and tranquillisers y Heroin and methadone41 Long Terms Risks As referred to earlier, 21 standard drinks and 14 standard drinks spread over the course of a week are the recommended limits for men and women respectively. For women, up to 35 standard drinks would indicate an increasing risk, with more than 35 standard drinks being considered harmful alcohol use. The equivalent figures for men are up to 50 standard drinks increasing risk and more than 50 drinks leading to harmful alcohol use. There is a wide range of long term risks associated with heavy and prolonged use of alcohol. This is an overview of som e of the provisions, and should not be taken as a definitive statem ent.

Because of the high costs generic viagra sublingual 100mg with visa, multi- center trials that utilize cooperation between many research centers and are funded by industry or government are becoming more common 100 mg viagra sublingual. Unfortunately buy generic viagra sublingual 100 mg online, the high cost of these studies has resulted in more of them being paid for by large biomedical (pharmaceutical or technology) companies and as a result, the design of these studies could favor the outcome that is desired by the sponsoring agency. This could represent a conflict of interest for the researcher, whose salary and research support is dependent on the largess of the company providing the money. Other factors that may compromise the research results are patient attri- tion and patient compliance. There may be ethical problems when the study involves giving potentially harmful, or withholding potentially beneficial, therapy. It is still the reader’s responsibility to determine how valid a study is based upon the methodology. In addition, the fact that a study is a ran- domized controlled trial does not in itself guarantee validity, and there can still be serious methodological problems that will bias the results. Albert Einstein (1879–1955) Learning objectives In this chapter you will learn: r different types of data as basic elements of descriptive statistics r instrumentation and measurement r precision, accuracy, reliability, and validity r how researchers should optimize these factors All clinical research studies involve observations and measurements of the phe- nomena of interest. The instruments used to make them are subject to error, which may bias the results of a study. The first thing we will discuss is the type of data that can be generated from clinical research. This chapter will then introduce concepts related to instruments and measurements. They can be classified by their function as independent or dependent variables, their nature as nominal, ordi- nal, interval, or ratio variables, and whether they are continuous, discrete, or dichotomous variables. When classifying variables by function we want to know what the variable does in the experiment. The independent variable is under the con- trol of or can be manipulated by the investigator. Generally this is the cause we 67 68 Essential Evidence-Based Medicine are interested in, such as a drug, a treatment, a risk factor, or a diagnostic test. The dependent variable changes as a result of or as an effect of the action of the independent variable. It is usually the outcome of exposure to the treatment or risk factor, or the presence of a particular diagnosis. We want to find out if chang- ing the independent variable will produce a change in the dependent variable. The nature of each variable should be evident from the study design or there is a serious problem in the way the study was conducted. When classifying variables by their nature, we mean the hierarchy that describes the mathematical characteristics of the value generated for that vari- able. The choice of variables becomes very important in the application of statis- tical tests to the data. One can assign a number to each of these categories, but it would have no intrinsic significance and cannot be used to compare one piece of the data set to another. Exam- ples of nominal data are classification of physicians by specialty or of patients by the type of cancer from which they suffer. There is no relationship between the various types of specialty physicians except that they are all physicians and went to medical school. Ordinal data are nominal data for which the order of the variables has impor- tance and intrinsic meaning. Typical examples of ordinal data include certain pain scores that are measured by scales called Likert scales, severity of injury scores as reflected in a score such as the Trauma Score where lower numbers are pre- dictive of worse survival than higher ones, or the grading and staging of a tumor where higher number stages are worse than lower ones. Common questionnaires asking the participant to state whether they agree, are neutral, or disagree with a statement are also examples of an ordinal scale. Although there is a directional value to each of these answers, there is no numerical or mathematical relation- ship between them. Interval data are ordinal data for which the interval between each number is also a meaningful real number. However, interval data have only an arbitrary zero point and, therefore, there is no proportionality ratio relationship between two points. One example is temperature in degrees Celsius where 64◦Cis32 C hotter◦ than 32◦C but not twice as hot. This makes the results take on meaning for both absolute and relative changes in the vari- able. Examples of ratio variables are the temperature in degrees Kelvin where 100◦ Kelvin is 50◦K hotter than 50◦K and is twice as hot, age where a 10-year- old is twice as old as a 5-year-old, and common biological measurements such Instruments and measurements: precision and validity 69 as pulse, blood pressure, respiratory rate, blood chemistry measurements, and weight. This is called the number of significant places, which is taught in high school and college, although it is often forgotten by students quickly thereafter. Height is an example of a continuous measure since a person can be 172 cm or 173 cm or 172. For exam- ple, a piano is an instrument with only discrete values in that there are only 88 keys, therefore, only 88 possible notes. Scoring systems like the Glasgow Coma Score for measuring neurological deficits, the Likert scales mentioned above, and other ordinal scales contain only discrete variables and mathematically can have only integer values. We commonly use dichotomous data to describe binomial outcomes, which are those variables that can have only two possible values. Obvious examples are alive or dead, yes or no, normal or abnormal, and better or worse. This has the effect of dichotomizing the value of the serum sodium into either hypernatremic or not hypernatremic. Measurement in clinical research All natural phenomena can be measured, but it is important to realize that errors may occur in the process. Random error leads to a lack of precision due to the innate variability of the biological or sociological system being studied. For example, in a given popula- tion, there will be a more or less random variation in the pulse or blood pres- sure. Many of these random events can be described by the normal distribution, which we will discuss in Chapter 9. An imprecise instrument will get slightly different results each time the same event is measured. For example, serum sodium measured inside rat muscle cells will show less random error than the degree of depression in humans. There can also be innate variability in the way that 70 Essential Evidence-Based Medicine different researchers or practicing physicians interpret various data on certain patients. Systematic error represents a consistent distortion in direction or magni- tude of the results.

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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www buy viagra sublingual no prescription. His research interests and health-care reform initiatives include patient-centered primary care and medical homes purchase viagra sublingual 100mg amex, care management and coordination viagra sublingual 100 mg without a prescription, total health management, workplace health promotion, risk- reduction program measurement, value-based health-care purchasing, and global occupational and health services delivery. Thompson Distinguished Fellow Award from Yale University and the Distinguished Alumnus Award for Professional Achievement from the University of Iowa. His team has received numerous national and interna- tional awards in health care, health promotion, and occupational health and safety. He is also the director of the Asian Liver Center and director of the Multidisciplinary Liver Cancer Program at the same institution. He has published numerous studies on solid-organ transplanta- tion and gastric and liver cancers. So is well known for his work on hepatitis B and liver-cancer education and prevention programs. So has identifed the need for a public-health approach to liver-cancer prevention in recent Asian immigrants and frst- and second- generation Asians living in the United States. For his work in education and prevention, he received the 2005 National Leadership Award from the New York University Center for the Study of Asian American Health, the 2008 American Liver Foundation Salute to Excellence Award, and the 2009 Asian Pacifc Islander Heritage Award from the California Asian Pacifc Islander Joint Legislative Caucus. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. He is also a professor in the Department of Epidemiology in the Johns Hopkins Bloomberg School of Public Health. Wright worked in several state and county health de- partments, including the Virginia Department of Health and the Delaware Public Health Division. He spent 7 years working in Africa on delivery of primary health care and health-system development. He has served on two National Academies committees: the Committee on Regulating Occu- pational Exposure to Tuberculosis and the Committee on the Elimination of Tuberculosis in the United States. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See also At-risk populations; specifc Gynecologists, 84, 97 populations Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See also of chronic hepatitis Foreign-born access to care, 56, 169 educational programs for, 87, 92, 93, B 153, 183 Baltimore, 28, 92, 122-123, 190 health-care providers, 82 Blacks. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See also Partner services Central nervous system demyelinating education of, 97, 98 disorders, 32 vaccination, 54, 57-58, 62, 93, 117, Chicago, 28, 116, 121 119-120 Childhood Immunization Initiative, 126 Correctional facilities. See also Liver cancer and discrimination liver cirrhosis age at exposure and, 19, 22, 46, 51, 82- Drug treatment programs and facilities. See also Illicit-drug users 83, 113, 117, 118, 156 knowledge of, 80, 83, 89 educational programs on viral hepatitis, 8, 88-89, 95-96, 100, 176 Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See Illicit-drug users Infectious Diseases program, 59 Exposure routes knowledge and awareness, 95 E sexual, 1, 23, 44, 72, 84, 119-120 unsafe vaccine injections, 24 Economic issues. See also Funding; Insurance coverage screening and testing, 27, 161-162, 163 F vaccination, 54, 57-58, 117-119, 124, 137-138 Federal Employees Health Benefts Program, Educational programs. See also Knowledge 5, 13, 130, 148, 172 and awareness of chronic hepatitis Florida Hepatitis Prevention Program, advocacy efforts, 153-154 186-187 for alternative-medicine professionals, Food and Drug Administration, 109 86, 87, 89 Foreign-born populations. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See also Vaccination for also Liver cancer and liver cirrhosis Hepatitis B; specifc populations and public vaccine programs and insurance, services 128-132 acute infection, 1, 19, 23, 27, 34, 48, racial/ethnic differences, 27, 29 50, 59, 70-71, 99, 117, 118, 119, reactivation, 162 120, 121, 125, 161, 189 registries of immunization, 126-127 adults, 27, 47, 117-125, 132 risk factors, 27 at-risk populations, 1-2, 21-22, 27, 81- screening and testing, 5, 8, 13, 14, 23, 82, 120-125 27, 47, 48-49, 51, 81, 82-83, 86, 90, case defnition, 48, 50, 51, 52 91, 124-125, 152, 156-157, 160-162 causative agent, 19, 21 stigma/discrimination, 23, 91-92 children, 23, 25, 30, 47, 116-117, surveillance, 44, 46, 47, 48, 50, 51, 52, 128-132 59-60, 61, 64, 71 Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See Liver cancer referral for medical management, 148 and liver cirrhosis screening, testing, and counseling, 14, High-risk populations. See At-risk 62, 83, 85, 86, 94, 148, 156-157, populations Hispanics, 2, 10, 27, 30, 93, 116, 121, 159, 158, 162, 163, 179 stigmatization and discrimination, 24, 168-169, 184-185 85 Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See also Foreign-born Insurance coverage populations gaps and barriers, 11, 134-135, 170 Immunization. See also Educational surveillance, 62 programs vaccination, 121-124, 157, 185 age and, 93 viral health services, 6, 16, 149, 184-186 asymptomatic infected individuals, 1, 3, Incidence of hepatitis. See Prevalence and 24, 26, 27, 50, 51, 90 incidence of hepatitis at-risk populations, 3, 4, 8, 9, 13, 34, Infants. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. See Viral hepatitis services applications of data from, 41, 42, 43-46 Sexual exposure to hepatitis, 1, 23, 44, 72, at-risk populations, 2, 4, 6, 7, 32, 61-62, 84, 113, 119-120 67, 68, 71-72 Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Request reprint permission for this book Copyright © National Academy of Sciences. The members of the Committee responsible for the report were chosen for their special competences and with regard for appropriate balance. N01-0D-4-2139 between the National Academy of Sciences and the National Institutes of Health. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.