Outbreak Report: Investigating the Typhoid Epidemic in Tajikistan

by Herman Bailey | Feb 25, 2023 | Essays | 0 comments

Please follow the below guideline for the outbreak report of Typhoid in Tajikistan

OUTBREAK INVESTIGATION REPORT WRITING GUIDELINE

1. Introduction

[A brief summary of the outbreak/setting the scene (this report is about…will discuss this and that and finally summarise key findings….outline some public health interventions to control outbreak]

1. Background

[Briefly describe- when outbreak occurred; how the outbreak was discovered; where or what sources (e.g. foods) were implicated; important facts to be drawn out; total number; summary of the case investigated and anything else that may be of relevance e.g. previous outbreaks]

1. Investigation of the outbreak

[Highlight some epidemiological, environmental and microbiological aspects]

1. Confirm that this is really an outbreak

[What sort of data was collected, what you know about the usual prevalence of these microorganisms e.g. surveillance systems].Describe the data you have so far [You are required to mention setting up an outbreak control committee and talk about control measures].

2. put together a case definition (person, place, time symptoms)

3. Describe how other cases were found e.g. GP alerts or use ofquestionnaires to collect information on cases.

4. Describe cases, what sort of outbreak is this? Any informationabout incubation period, age and gender of cases?

5. Put together a hypothesis on the likely source and vehicle associated with outbreak

6. Test hypothesis usually case/control study including Odds ratio. How are the controls recruited? (If needed or given)

7. What other information might be used to confirm the hypothesis? E.g. sampling of environment and/or food.

8. Recommendations to prevent future outbreaks (control measures)

[Infection control, policy changes, public information]

1. Discussion and conclusion
2. Lessons learned and recommendations
3. References (Harvard – APA style]

Note

Assessment Component: 1 (2000 words, +/-10%) Weighting: 40%

Outbreak investigation report must be submitted and electronically (using Turnitin)!

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Typhoid in Tajikistan

PART I. OUTBREAK DETECTION

Tajikistan is one of five Central Asian countries that were formerly part of the Soviet Union (Figure 1). Tajikistan is one of the poorest of these countries, with less than 7% of its land available for cultivation.

Figure 1.Location of Tajikistan including the country’s capital and largest city, Dushanbe.

Tajikistan became an independent nation in 1991 as the result of the dissolution of the former Soviet Union. The shift in its status from being a member of a totalitarian republic to an independent nation brought with it certain challenges. Basic public services (e.g., health care, water supply, and sewer systems), previously guaranteed for even the poorest nations in the Soviet Union, were no longer supported through the Soviet cost-sharing system. Financial hardships and inadequate tariffs in Tajikistan severely limited provision of services and maintenance of equipment. Faulty design and installation of equipment while Tajikistan was still part of the Soviet Union added to these problems.

To make matters worse, shortly after becoming an independent nation, Tajikistan experienced a civil war that continued until a cease-fire occurred in 1996. During the civil war, an estimated 50,000 lives were lost and 1.2 million persons were internally displaced.3 In addition, a substantial number of trained technical and professional workers left the country.

By 1997, the country’s economy and much of its infrastructure had collapsed. Consequently, the health of the people of Tajikistan suffered. Diseases rarely seen before the dissolution of the Soviet Union reappeared in increasing numbers.

Residents of Tajikistan received primary health care at designated polyclinics on the basis of their place of residence. The polyclinics provided ambulatory care and certain acute care services but lacked surgical and post-operative care facilities. Limited hospital beds at nationally run hospitals were available for patients needing in-patient services. Cases of notifiable disease were reported each week from the polyclinics and hospitals to the Sanitary Epidemiologic Service (SES), the public health unit that monitored infectious diseases.

In February 1997, an increase in typhoid fever cases was reported in Dushanbe, the capital of Tajikistan (population approximately 600,000). Although typhoid fever was endemic in this area, more than 2,000 cases had been reported during January 29−February 11 (i.e., a 2-week period), compared with approximately 75 cases each week during the previous month. During the same 2-week period in 1996, only 23 cases had been reported.

All typhoid fever patients were hospitalized at one of six full-service hospitals in the city, as required by a central government edict. SES staff studied the situation to determine the likelihood of an outbreak.

As a first step in exploring the increase in typhoid fever cases in Tajikistan, SES investigators confirmed the diagnosis of typhoid fever in a sample of patients admitted to one of the Dushanbe hospitals. They also examined laboratory testing procedures and reagents at all six hospitals. No evidence of laboratory error or contamination of cultures was identified.

SES investigators were unable to identify recent events that might have led to an increase in the completeness of case reporting. Notifiable disease reporting procedures had not changed since the early 1980s. Typhoid in Tajikistan Page 3

SES investigators noted that the civil war had resulted in the displacement of substantial numbers of Tajikistan citizens and an increase in the Dushanbe population. However, movement of the displaced persons was spread over a lengthy period and seemed an unlikely explanation for the sudden increase in typhoid fever cases during January−February of 1997.

SES staff concluded that the increase in typhoid fever cases was real and likely represented an outbreak. Because previous typhoid fever outbreaks had been associated with foods and beverages sold by street vendors, the city government prohibited such sales. However, considerable debate remained about the source of the outbreak and appropriate control measures.

PART II. HYPOTHESIS GENERATION

SES investigators pursued different lines of investigation to gain clues about the typhoid fever outbreak in Dushanbe. The first step was to review known information about the disease and risk factors on the basis of its epidemiology and previous outbreaks.

SES staff then reviewed the typhoid fever cases reported through the notifiable disease surveillance system and characterized the cases by person, place, and time (i.e., performed the descriptive epidemiology).

To characterize the typhoid fever cases associated with the Dushanbe outbreak, SES investigators defined a case of typhoid fever as a physician diagnosis of typhoid fever or isolation of Salmonella Typhi from the stool, blood, or urine of a Dushanbe resident (i.e., a relatively sensitive case definition). Investigators analyzed typhoid fever cases reported to SES with onset of illness since January 1.

A total of 3,822 patients meeting the typhoid fever case definition had onset of illness since January 1. Of these cases, 127 had onset of illness from January 1−14 (median of 64 cases each week) and 3,695 had onset of illness from January 15 to February 18 (median of 724 cases each week) (Figure 2).

Among the cases reported during January 15−February 18, the following signs and symptoms were reported: sustained fever (91% of cases), headache (81%), weakness (76%), chills (73%), loss of appetite (67%), abdominal pain (51%), vomiting (39%), diarrhea (30%), and rose-colored spots (6%). Blood, stool, or urine cultures confirmed 1,145 (31%) of the cases.

The median age of patients was 16 years (range: <1−80 years); 51% were male. Cases were spread across the city with varying rates of infection by polyclinic catchment area (Figure 3).

Forty-eight (1.3%) of the 3,695 patients had died. Mortality rates were lowest among patients aged <10 years (0.3%) and highest among those aged >39 years (1.4%). Typhoid in Tajikistan Page 4

Figure 2. Cases of typhoid fever by week of onset of illness, Dushanbe, Tajikistan, June 1996−February

Source: Dushanbe SES Notifiable Disease Surveillance System.

Figure 3.Incidence rate of typhoid fever by registered polyclinic, Dushanbe, Tajikistan, January 15–February 18, 1997.

Source: Dushanbe SES Notifiable Disease Surveillance System.

Detailed hypothesis-generating interviews were conducted to detect common and suspicious exposures among a sample of the typhoid fever patients. Interviews were undertaken with 10 patients who had culture-confirmed illness. These patients lived in the catchment areas of five different polyclinics and ranged in age from 5 to 69 years. Six of the patients were female. All of the patients had had onset of symptoms during the first 2 weeks of February.

Hypothesis-generating interviews revealed that all of the patients had purchased groceries from state-approved markets. However, four of the patients had also purchased food from local street vendors, with fruits and vegetables being the most commonly purchased items. No market, street vendor, restaurant, or social event was identified in common among the patients.

The households of all patients included in hypothesis-generating interviews were supplied with public water. All but one patient reported that the water was often cloudy and occasionally had a foul smell.

Only one patient had travelled outside the city during the previous 6 weeks; seven patients had had visitors who normally resided outside Dushanbe staying in their home because of Ramadan (i.e., a month-long Muslim observance involving a fast from food and water from sunrise to sunset that began on January 10). None of the patients knew each other. Two patients knew someone else who had been similarly ill.

SES investigators suspected the public water supply as the source of the Dushanbe typhoid fever outbreak. The widespread occurrence of cases throughout the city, affecting both sexes and all age groups, was indicative of a waterborne outbreak. Complaints during the hypothesis-generating interviews about the quality of the public water further heightened their suspicions.

Investigators initiated both epidemiologic and environmental health studies to confirm their hypothesis.

PART III. AN EPIDEMIOLOGIC STUDY TO TEST THE HYPOTHESIS

SES investigators conducted a case-control study to test the hypothesis that the public water system was the source of the typhoid fever outbreak in Dushanbe.

Beginning March 24, patients hospitalized with typhoid fever in Dushanbe were recruited to participate in the case-control study. For the study, a case was defined as an illness in a person that included the following:

Clinical criteria

– sustained fever (i.e., oral temperature ≥ 101.5 F [38.5C] for ≥7 days), and

– one or more other signs and symptoms indicative of typhoid fever (e.g., weakness, stomach pains, headache, loss of appetite, or rose-colored rash), and

– culture of stool or blood positive for Salmonella Typhi.

Restrictions on time, place, and person

– onset of symptoms after February 1,

– resident of Dushanbe, and

– person with earliest onset of symptoms in household.

Case-patients were interviewed within 5 days of hospital admission by a trained SES interviewer, using a standardized questionnaire. Questions focused on exposures during the 30 days before onset of illness.

Within 5 days of interviewing each case-patient, investigators selected neighbourhood control

subjects from households in which no one had experienced fever for ≥3 consecutive days during the Typhoid in Tajikistan Page 6

previous 90 days. Control subjects were recruited by going systematically from door-to-door, starting at the case-patient’s house; control subjects were then matched with case-patients by age group.

Two to three control subjects were identified for each case-patient.

Control subjects were interviewed by using the same standardized questionnaire as case-patients, except that exposure information was requested for the 30 days before the interview.

During March 24−April 7, a total of 45 case-patients and 123 healthy control subjects were enrolled in the case-control study. SES investigators tabulated the results and set a P value of 0.05 as the cut-off for statistical significance.

On the basis of these analyses, case-patients were similar to control subjects with respect to age, sex, and nationality (Table 1). Exposure to potential risk factors for infection with S. Typhi, however, differed between case-patients and control subjects (Table 2).

Tables 1.Characteristics of case-patients and control subjects, case-control study, Dushanbe, Tajikistan, 1997.

Table 2. Exposures to selected risk factors for infection with Salmonella Typhi, case-control study, Dushanbe, Tajikistan, 1997

*Exposure during the 30 days before becoming ill (case-patients) and during the 30 days before the interview (control subjects)

†Denominator does not always total to 45 (case-patients) or 123 (control subjects) because certain subjects could not remember if they had had the exposure.

On the basis of the matched case-control study, infection with S. Typhi in Dushanbe was associated with drinking water that had not been boiled during the 30 days before onset of symptoms. The odds ratio increased with the amount of water consumed each day (Figure 4). Drinking at least 1 glass of water that had not been boiled had a matched odds ratio of 3; drinking 2 glasses had a matched odds ratio of 12; and drinking > 2 glasses had a matched odds ratio of 40.

Obtaining water from a tap outside the home and eating food obtained from street vendors were also associated with illness. Using boiled water in the home and eating butter, apples, or onions were determined to be protective factors.

Factors not associated with illness (data not shown) included type of toilet facilities; drinking beverages with ice; eating or drinking at restaurants or a friend’s or relative’s home; travelling outside Dushanbe or receiving visitors who usually reside outside Dushanbe; and consuming raw fruits and vegetables (other than apples and onions), dairy products (other than butter), and medicines.

Figure 4. Odds ratios by amount of water consumed per day that had not been boiled, case-control study, Dushanbe,Tajikistan, 1997.

Investigators undertook a multivariate logistic regression analysis that included all exposures identified as significantly associated with infection in the univariate analysis (Table 3).

Table 3. Multivariate analysis of reported exposures to risk factors for infection with Salmonella Typhi, case-control study, Dushanbe, Tajikistan, 1997

PART IV. ENVIRONMENTAL STUDIES AND WATER SUPPLY INVESTIGATION

Concurrent with the case-control study, SES investigators evaluated the Dushanbe public water supply to identify factors that might have allowed introduction of pathogenic organisms into the drinking water or the survival of such organisms.

To evaluate the Dushanbe public water supply, SES investigators first talked with the superintendent of public water and viewed maps of the watersheds for the water treatment plants. They then toured all of the water treatment plants (and associated wells) and spoke with water treatment plant operators and maintenance technicians. Investigators observed procedures used to treat the water at each plant and inspected equipment used in water treatment.

SES investigators learned that the city of Dushanbe had four water treatment plants that used surface and groundwater. The two treatment plants in the northern part of the city (i.e., the Napornaya and Samotechnaya Stations) used surface water from the Varzob River. The two treatment plants in the southern part of the city (i.e., the Kafernigan and South-West Stations) used groundwater.

The Varzob River’s source is in the Hissar Mountain range, 72 km north of Dushanbe, and is fed by the Siyoma, Ojuk, Kondara, Maikhura and Tagob Rivers. Heavy rains in the winter and spring and snowmelt result in periodic flash floods along the watershed. Lack of wastewater purification facilities or storage in villages and factories along the river resulted in the discharge of communal wastes directly into the river. Within the Dushanbe city limits, water was drawn from the Varzob River through a system of canals into the surface water treatment plants (i.e., Napornaya and Samotechnaya Stations).

Typically, the water was strained and held in open sedimentation basins where particulates were allowed to settle out naturally. Chlorine was added directly to the sedimentation basins before the water was passed through sand filters to allow for adequate contact time. From the filters, water was pumped into the distribution system without further storage.

The water for the two groundwater treatment plants (i.e., Kafernigan and South-West Stations) was pumped directly from the wells into holding tanks and from the holding tanks into the public water distribution system without treatment.

On inspection of the surface water treatment stations, investigators noted that the sedimentation basins were filled with silt and algae. Dredging machines used to remove the silt were broken. Sand filters had formed mud balls (i.e., conglomerations of filter material that form if a filter is not cleaned adequately) and displayed substantial fouling with iron-oxide that can compromise the filtration process. Water at the surface water treatment stations had not been chlorinated regularly since December. The chlorine -producing facility in Yavan, Tajikistan, which once supplied chlorine to the entire country, had closed in 1996.

Inspections of the groundwater treatment stations were unrevealing. The wells were in good condition and wellhead seals were functioning correctly. However, approximately half of the pumps at these stations were not operational, limiting the ability to provide the city with adequate water pressure. Plant workers had scavenged spare parts to maintain the functionality of the remaining pumps. Typhoid in Tajikistan Page 10

SES investigators tested treated water samples from each of the water treatment plants for turbidity and fecal coliforms. The turbidity of treated water from the Napornaya Station was 150 nephelometric turbidity units (NTUs). Fecal coliforms were 132 colony forming units (CFU)/100 mL. Treated water from the Samotechnaya Station had a turbidity of 70 NTUs; fecal coliforms were 118 CFU/100 mL. Both groundwater plants pumped fecal-coliform-free water with a turbidity of 0 NTUs.

Water leaving all four water treatment plants entered an interconnected distribution system where surface and groundwater blended. To distinguish the source of water supplied to different parts of the city, SES investigators measured water hardness at the treatment plants and at a sample of consumer taps. They determined that the northern part of the city received water primarily from the surface water treatment plants. The southern part of the city received water primarily from the groundwater treatment plants. The central part of the city received water from both the surface and the ground water treatment plants (Figure 5).

Figure 5. Water source by polyclinic, Dushanbe, Tajikistan, 1997

The water distribution system in Dushanbe was approximately 690 km in total length and consisted mainly of steel and cast-iron pipelines. Approximately 5% of pipes were asbestos or plastic. Distribution pipes had corroded over the years, and breaks occurred intermittently throughout the city.

SES investigators undertook a community survey to assess domestic water quality and use in Dushanbe. Households were selected from each polyclinic catchment area by using a stratified random-sampling scheme. At each house or apartment, investigators recorded the number of residents, frequency of water outages and other problems, and attitudes toward water use. They also collected water from the tap for fecal coliform testing and quantified water usage.

SES investigators learned that low and intermittent water pressure was common across the city, resulting in water outages on a daily basis. Apartment buildings often had supplemental water pumps that were activated at times of low water pressure. Residents in households and apartment buildings without supplemental water pumps were forced to obtain water from outside taps. In addition, nonstandard connections to waterlines were commonly used to supply homes. Investigators also observed that water pipes ran inside storm drains along roadsides.

Water usage at the surveyed households was substantial. On average, 1,000 L of water were used/person/day, the majority of which was wasted. A total of 300 L/person/day were lost because of open taps within the households, and another 300 L/person/day were lost because of broken pipes or faucets within the house. An additional 400 L/person/day were wasted because of open or broken taps or pipes in public areas. (Note: For comparison, according to a 2006 United

Nations Development Programme report,4water usage was approximately 575 L/person/day in the United States and 200−300 L/person/day in Europe.)

Surveyed residents considered the water supply a free commodity. Approximately 2% of domestic users paid the tariff charged by the public water utility, which by the majority of standards was quite low (i.e., US$0.004/1,000 L equivalent for domestic consumers). Residents did not consider running taps to be wasteful or as a contributing factor to the typhoid fever epidemic.

Based on the water samples collected during the survey, 97% of household and community taps throughout the city had water contaminated with fecal coliforms. The average fecal coliform concentration in water samples was 175 CFU/100 mL.

PART V. PREVENTION AND CONTROL MEASURES

Prevention and control of typhoid fever and other waterborne diseases in Dushanbe required many actions, including improved protection of the watershed of the Varzob River, repair or replacement of equipment at the water treatment plants (e.g., dredging machinery, sand filters, and pumps), thorough training of water treatment plant staff, changes to the water treatment processes, procurement of adequate amounts of chlorine and coagulant, and repair and replacement of the aging water distribution system. In addition, public education on water conservation was needed to decrease water wastage across the city.

Officials estimated that these efforts might cost at least US$150 million and require yearstocomplete. Public health officials considered implementing point-of -use water treatment to protect the public’s health while more costly improvements were being made to the water system.

SES investigators worked with the Tajikistan Ministry of Health in developing a citywide public education campaign about point-of-use water treatment. A health educator from the Ministry of Health was designated to lead and coordinate campaign efforts.

EPILOGUE

Use of multiple barriers to keep water contaminants from entering the water supply and surviving is the best approach to achieving a healthy public water supply. Development of multiple barriers to protect the water means that the system will continue to perform adequately despite the failure of part of the system.

The Dushanbe typhoid fever outbreak resulted from failures at multiple points in the water treatment and distribution process. The factors contributing to the state of water services in Dushanbe included

• Chronically contaminated surface waters caused by discharge of untreated sewage into the river and heavy flooding each spring;

• inadequate treatment processes (e.g., lack of chlorination because of inadequate supplies, improperly maintained sand filters, and lack of residual chlorine levels in water leaving the water treatment stations);

• disrepair of the water treatment plants resulting from inadequate initial design, unavailable or low-quality of materials and equipment, limited financial resources, and departure of trained staff;

• frequent low and intermittent water pressure because of nonoperational water pumps at treatment facilities, breakages in the water distribution lines, and water wastage in the community; and

• Inadequate monitoring of the water system to identify and correct problems.

In 2002, the World Bank began funding the Dushanbe Water Supply Project. Loans were approved to address the most critical deficiencies of the water supply, including replacement of pumps and other equipment at the treatment plants and repair of major sections of the distribution system. Despite improvements, many Dushanbe residents still had inadequate water service and outbreaks of typhoid fever reoccurred on an annual basis. In 2006, the World Bank approved additional funds to continue work on the water system. Renovations and repairs are ongoing.5

Although the investigation of the typhoid fever outbreak in Dushanbe presents a dramatic third world image, similar problems occur elsewhere. In 2007, the U.S. Environmental Protection Agency estimated that 240,000 water mains in the United States break each year, resulting in a loss of 1.7 trillion gallons of water.6 These problems are attributed to factors that are reminiscent of the Dushanbe situation and include reductions in resources devoted to water treatment system maintenance, a growing backlog of needed repairs, aging treatment equipment and distribution pipes, and loss of trained personnel to maintain the systems.

In the majority of U.S. cities, water supplies have not yet been adversely affected. However, a growing number of localities have had serious problems resulting in at least a temporary loss of

Although the investigation of the typhoid fever outbreak in Dushanbe presents a dramatic third world image, similar problems occur elsewhere. In 2007, the U.S. Environmental Protection Agency estimated that 240,000 water mains in the United States break each year, resulting in a loss of 1.7 trillion gallons of water.6 These problems are attributed to factors that are reminiscent of the Dushanbe situation and include reductions in resources devoted to water treatment system maintenance, a growing backlog of needed repairs, aging treatment equipment and distribution pipes, and loss of trained personnel to maintain the systems.

In the majority of U.S. cities, water supplies have not yet been adversely affected. However, a growing number of localities have had serious problems resulting in at least a temporary loss of potable water and substantial commitment of resources to correct the problem. If steps are not taken to understand and address these growing problems, a widespread decline in drinking water quality and reliability, even in the United States, is possible.

REFERENCES

1. Mermin JH, Villar R, Carpenter J, et al. Massive epidemic of multidrug-resistant typhoid fever in Tajikistan associated with consumption of municipal water. J Infect Dis 1999;179:1416–22.

2. Centers for Disease Control and Prevention (CDC). Epidemic typhoid fever—Dushanbe, Tajikistan, 1997. MMWR Morb Mortal Wkly Rep 1998;47:752–6. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00054823.htm. Accessed September 20, 2010.

3. United Nations. Tajikistan: rising from the ashes of civil war. Available at: http://www.un.org/events/tenstories_2006/story.asp?storyID=600. Accessed September 20, 2010.

4. United Nations Development Programme. Human Development Report 2006. Beyond Scarcity: Power, Poverty and the Global Water Crisis. New York: Palgrave Macmillan; 2006. Available at: http://hdr.undp.org/en/media/HDR06-complete.pdf. Accessed September 20, 2010.

5. World Bank. Project paper on a proposed additional financing grant for a Dushanbe water supply project.. Report No. 38085-TJ. Available at: http://waterwiki.net/images/3/32/WB_Project_Paper_Dushanbe_Financing_WS.pdf. Accessed September 20, 2010.

6. US Environmental Protection Agency (EPA). Aging water infrastructure research program: addressing the challenge through innovation. Washington, DC: EPA; 2007. Available at: http://www.epa.gov/nrmrl/pubs/600f07015/600f07015.pdf. Accessed September 20, 2010.

ADDITIONAL RESOURCES

Arnold BF, Colford JM. Treating water with chlorine at point-of-use to improve water quality and reduce childhood diarrhea in developing countries: a systematic review and meta-analysis. Am J Trop Med Hyg 2007;76:354–64.

Australian Cooperative Research Centre (CRC) for Water Quality and Treatment. Drinking water facts.Drinking water treatment. Adelaide, South Australia: CRC; 2008. Available at: http://www.wqra.com.au/crc_ archive/dwfacts/DWF_Drinking_Water_Treatment_Nov08.pdf. Accessed on September 20, 2010.

Clasen T, Schmidt W-P, Rabie T, Roberts I, Cairncross S. Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis. BrMed J 2007;334:782−792. Available at: http://www.bmj.com/content/early/2006/12/31/bmj.39118.489931.BE.full.pdf+html?maxtoshow=&HIT S=10&hits=10&RESULTFORMAT=&fulltext=clasen&searchid=1&FIRSTINDEX=0&resourcetype=H WCIT. Accessed on September 20, 2010.

Centers for Disease Control and Prevention (CDC). Preventing diarrheal disease in developing countries: proven household water treatment options. USAID-sponsored activity. Atlanta, GA: US Department of Health and Human Services, CDC; 2008. Available at: http://www.ehproject.org/PDF/ehkm/cdc-proven.pdf. Accessed September 20, 2010.

Centers for Disease Control and Prevention (CDC). Safe Water Systems for the Developing World: A Handbook for Implementing Household-Based Water Treatment and Safe Storage Projects. Atlanta, GA: US Department of Health and Human Services, CDC; [undated]. Available at: http://www.cdc.gov/safewater/manual/sws_manual.pdf. Accessed September 20, 2010.Typhoid in Tajikistan Page 14

Committee on Communicable Diseases Affecting Man, Food Subcommittee. Procedures to Investigate Waterborne Illness, 2nd ed. Ames, Iowa: International Association of Milk, Food, and Environmental Sanitarians, Inc (IAMFES); 1996.

U.S. Environmental Protection Agency (EPA). Drinking water glossary: a dictionary of technical and legal terms related to drinking water. Washington, DC: EPA; 2009. Available at: http://www.epa.gov/safewater/pubs/gloss2.html. Accessed September 20, 2010.

Hrudey WE, Huck PM, Payment P, Gillham RW, and Hrudey EJ. Walkerton: lessons learned in comparison with waterborne outbreaks in the developed world. J Environ SciEng 2002;1:397–407.

Lantagne DS, Quick R, and Mintz ED. Household water treatment and safe storage options in developing countries: a review of current implementation practices. Washington, DC: Woodrow Wilson International Center for Scholars; 2007. Available at: http://www.wilsoncenter.org/topics/pubs/WaterStoriesHousehold.pdf. Accessed September 20, 2010.

LeChevallier MW, Au K-K. Water Treatment and Pathogen Control: Process Efficiency in Achieving Safe Drinking Water. Geneva, Switzerland: World Health Organization and IWA Publishing; 2004. Available at: http://www.who.int/water_sanitation_health/dwq/watreatment/en/index.html. Accessed September 20, 2010.

National Environmental Services Center.National drinking water clearinghouse [Homepage on the Internet]. Morgantown, WV: University of West Virginia; 2010. Available at: http://www.nesc.wvu.edu/drinkingwater.cfm. Accessed September 20, 2010.

World Health Organization (WHO).Guidelines for Drinking Water Quality.2nd ed. Volume I. Recommendations. Geneva, Switzerland: WHO; 1993. Available at: http://www.who.int/water_sanitation_health/dwq/2edvol1b.pdf. Accessed September 20, 2010.Typhoid in Tajikistan Page 15

APPENDIX

APPENDIX A: Typhoid and Paratyphoid Fever (by Eric Mintz)

Infectious Agent

Typhoid fever is an acute, life-threatening febrile illness caused by the bacterium Salmonella entericaserotype Typhi. Paratyphoid fever is a similar illness caused by S. Paratyphi A, B, or C.

Mode of Transmission

• Humans are the only source. No animal or environmental reservoirs have been identified.

• Typhoid and paratyphoid fever are most often acquired through consumption of water or food that have been contaminated by feces of an acutely infected or convalescent individual or a chronic asymptomatic carrier.

• Transmission through sexual contact, especially among men who have sex with men, has rarely been documented.

Occurrence

• An estimated 22 million cases of typhoid fever and 200,000 related deaths occur worldwide each year; an additional 6 million cases of paratyphoid fever are estimated to occur annually.

• Approximately 400 cases of typhoid fever and 150 cases of paratyphoid fever are reported to CDC each year among persons with onset of illness in the United States, most of whom are recent travelers.

Risk for Travelers

• Risk is greatest for travelers to South Asia (6 to 30 times higher than all other destinations). Other areas of risk include East and Southeast Asia, Africa, the Caribbean, and Central and South America.

• Travelers to South Asia are at highest risk for infections that are nalidixic acid-resistant or multidrug-resistant (i.e., resistant to ampicillin, chloramphenicol, and trimethoprim– sulfamethoxazole).

• Travelers who are visiting friends or relatives are at increased risk.

• Although the risk of acquiring typhoid or paratyphoid fever increases with the duration of stay, travelers have acquired typhoid fever even during visits of less than 1 week to countries where the disease is endemic.

Clinical Presentation

• The incubation period of typhoid and paratyphoid infections is 6–30 days. The onset of illness is insidious, with gradually increasing fatigue and a fever that increases daily from low-grade to as high as 102° F–104° F (38.5° C–40° C) by the third to fourth day of illness. Headache, malaise, and anorexia are nearly universal. Hepatosplenomegaly can often be detected. A transient, macular rash of rose-colored spots can occasionally be seen on the trunk.

• Fever is commonly lowest in the morning, reaching a peak in late afternoon or evening. Untreated, the disease can last for a month. The serious complications of typhoid fever generally occur only after 2–3 weeks of illness, mainly intestinal haemorrhage or perforation, which can be life threatening.

Typhoid in Tajikistan Page 16

Diagnosis

• Infection with typhoid or paratyphoid fever results in a very low-grade septicemia. Blood culture is usually positive in only half the cases. Stool culture is not usually positive during the acute phase of the disease. Bone-marrow culture increases the diagnostic yield to about 80% of cases.

• The Widal test is an old serologic assay for detecting IgM and IgG antibodies to the O and H antigens of Salmonella. The test is unreliable, but is widely used in developing countries because of its low cost. Newer serologic assays are somewhat more sensitive and specific than the Widal test, but are infrequently available.

• Because there is no definitive test for typhoid or paratyphoid fever, the diagnosis often has to be made clinically. The combination of a history of being at risk for infection and a gradual onset of fever that increases in severity over several days should raise suspicion of typhoid or paratyphoid fever.

Treatment

• Specific antimicrobial therapy shortens the clinical course of typhoid fever and reduces the risk for death.

• Empiric treatment of typhoid or paratyphoid fever in most parts of the world would utilize a fluoroquinolone, most often ciprofloxacin. However, resistance to fluoroquinolones is highest in the Indian subcontinent and increasing in other areas. Injectable third-generation cephalosporins are often the empiric drug of choice when the possibility of fluoroquinolone resistance is high.

• Patients treated with an appropriate antibiotic still require 3–5 days to defervesce completely, although the height of the fever decreases each day. Patients may actually feel worse during the time that the fever is starting to go away. If fever does not subside within 5 days, alternative antimicrobial agents or other foci of infection should be considered.

Preventive Measures for Travelers

Vaccine

• CDC recommends typhoid vaccine for travelers to areas where there is a recognized increased risk of exposure to S. Typhi.

• The typhoid vaccines currently available do not offer protection against S. Paratyphi infection.

• Travelers should be reminded that typhoid immunization is not 100% effective, and typhoid fever could still occur.

• Two typhoid vaccines are currently available in the United States.

o Oral live, attenuated vaccine (Vivotif vaccine, manufactured from the Ty21a strain of S. Typhi by Crucell/Berna)

o Vi capsular polysaccharide vaccine (ViCPS) (Typhim Vi, manufactured by sanofipasteur) for intramuscular use

• Both vaccines protect 50%–80% of recipients.

• Table 2-10 provides information on vaccine dosage, administration, and revaccination. The time required for primary vaccination differs for the two vaccines, as do the lower age limits.

• Primary vaccination with oral Ty21a vaccine consists of four capsules, one taken every other day. The capsules should be kept refrigerated (not frozen), and all four doses must be taken to achieve maximum efficacy. Each capsule should be taken with cool liquid no warmer than 37° C (98.6° F), approximately 1 hour before a meal. This regimen should be completed 1 week before potential exposure. The vaccine manufacturer recommends that Ty21a not be administered to infants or children<6 years of age.

• Primary vaccination with ViCPS consists of one 0.5-mL (25-μg) dose administered intramuscularly.

Typhoid in Tajikistan Page 17

One dose of this vaccine should be given at least 2 weeks before expected exposure. The manufacturer does not recommend the vaccine for infants and children <2 years of age.

Vaccine Safety and Adverse Reactions

Information on adverse reactions is presented in Table 2-11. Information is not available on the safety of these vaccines in pregnancy; it is prudent on theoretical grounds to avoid vaccinating pregnant women. Live, attenuated Ty21a vaccine should not be given to immunocompromisedtravelers, including those infected with HIV. The intramuscular vaccine presents a theoretically safer alternative for this group. The only contraindication to vaccination with ViCPS vaccine is a history of severe local or systemic reactions after a previous dose. Neither of the available vaccines should be given to persons with an acute febrile illness.

Precautions and Contraindications

Theoretical concerns have been raised about the immunogenicity of live, attenuated Ty21a vaccine in persons concurrently receiving antimicrobials (including antimalarial chemoprophylaxis), IG, or viral vaccines. The growth of the live Ty21a strain is inhibited in vitro by various antibacterial agents. Vaccination with Ty21a should be delayed for >72 hours after the administration of any antibacterial agent. Available data do not suggest that simultaneous administration of oral polio or yellow fever vaccine decreases the immunogenicity of Ty21a. If typhoid vaccination is warranted, it should not be delayed because of administration of viral vaccines. Simultaneous administration of Ty21a and IG does not appear to pose a problem.

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

A Comparison of Fire Departments and City Services in Stratford and New Haven

by Herman Bailey | Feb 24, 2023 | Essays | 0 comments

Fire departments

The Stratford rescue and fire department is driven by a goal to protect and make the residents of city of Stratford safe. Administratively, the department makes use of the electronic media in accomplishing its goals. The department is well equipped with apparatus to handle any emerging fire emergency or related incident. According to Bain (48), the department believes that to be successful, prevention of losses and serious injuries from fire related incidents is the way forward. This is because if their information can enlighten the public and prevent any injuries and losses, then their success can be measured.

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On the other hand, the fire department of New Haven headed by fire chiefs is driven by the mission of contributing within their authority to improve and maintain the quality of life of haven city through these activities:

• Prevention and suppression of fire
• Emergency medical services
• Emergency management and communication
• Rescue operations
• Administration and training of the activities (Birch, 126)

Additionally, the staffs of the department  are grouped into different divisions such as the administration, investigation and inspection, emergency communication, apparatus maintenance, training, emergency medical service, fire suppression, emergency management, station maintenance.

However, the two departments share some similarity. Both have support services for civil defense which includes:

• Staffing and managing the emergency operations centre
• Coordination activities of the city that fall under emergency
• Participating in the state and the federal programs of emergency planning responses.

Moreover, they operate state of art repair and apparatus maintenance facilities. Both departments are always ready to respond to any emergency whenever they are called whether it is medical emergency, fire, automobile accident and incident of hazardous materials.

City service systems and policies

The city hall of Stratford besides addressing the city’s daily business, the mayor’s office also looks into special initiatives that impact the community directly such as the civility in series of America, alert program of Stratford, the youth empowerment program of the mayor, the program of preschool readiness and the youth services bureau of Stratford among others. Bain  (62) observes that the mayor’s office is a hub of dedicated professionals that uphold the quality of life to all the citizens of the Stratford city to enjoy. Moreover, the mayor’s cabinet members are also dedicated and closely work with the mayor to improve the city, create new opportunities that benefit the city of Stratford directly.

In comparison to the city Stratford, the city of New Haven has only seen one mayor since 1994. The office of the mayor has strengthened the academics in public schools, build a city center which is vibrant, has stable economic base, robust traditional cultures and values, strong neighborhoods and social tolerance (Birch, 73).

The economic policies of the city focus on two key area; Pursuit of mixed-use development and making New Haven the biotechnology economic hub, life sciences and research industries, pharmaceuticals. These key areas have been realized with much success because of the dense population in the city centre and its ranking among the top cities with lowest vacancy of commercial rates (Birch, 78).

Furthermore, around Connecticut which has 50 startups of biotech, 39 are found in New Haven is and 20 are found inside the city of New Haven. According to Birch (108), the city of New Haven boasts of vibrant economic culture social entrepreneurship that strengthens the city’s desire of developing mix –income housing and commercial corridors promotion within the neighbor hoods.

Similarly, the “street smart” developed infrastructure which is friendly to the bicyclists and the pedestrians makes the city with the most lenis for bicycles in Connecticut. Additionally, the successes of their economic policies are shown by the recovered jobs in2011 that were lost in the economic collapse of 2008 (Birch, 124)

Tax collection

The tax collector’s office in Stratford city has the responsibility of billing and collection of all the taxes in the city. These include taxes from the real estate, motor vehicle taxes, personal property taxes, sewer assessment taxes and connection fees that are owed to the city (Bain, 119).

On the other hand, in the city of New Haven, the administration office has the responsibility of  for developing, improving and maintaining the financial systems of the city, practices and policies and the internal controls; to execute administrative and financial  decisions in an accountable and administrative  manner; to advice the fiscal board of the city and the mayor with respect to administrative and financial matter in accordance with the city of New Haven’s charter, state law , local ordinance and to give executive leadership  to the  divisions  operating and functioning within the administration office. Furthermore, Birch (114) adds that realizing this mission is their mandate to ensure that the tax payers of Stratford benefit from prudent and sound administrative and financial management.

Work cited

Birch, D. L. (2012). Patterns of urban change: The New Haven experience. Lexington, Mass:      Lexington Books.

Bain, R. (2009). Stratford. Erin, Ont: Boston Mills Press.

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Jehovah Witness Beliefs: Implications on Healthcare and Strategies for Overcoming Barriers

by Herman Bailey | Feb 24, 2023 | Essays | 0 comments

History of the Jehovah Witness

Jehovah Witness is a religion that is widely known all over the world with a larger percentage of the members of the religion residing in the United States. Most members of the public would know the Jehovah witness from their door-to-door ministry of well-dressed individuals who visit people offering magazines and books for sale. Charles Russell, who was intrigued by religion and discovered the Adventist beliefs founded Jehovah witness. Russell then started bible study groups and a publishing company for religious books. His congregation commonly referred to him as Pastor Russell, then launched a Zion’s Watch Tower magazine. The group continued to grow and in 1961, they published a new Bible Translation, it was then that they decided to have their own interpretation of the Bible that did not contravene God’s laws. The name Jehovah Witnesses was drawn from the Bible in accordance with Russell’s interpretation (Agapidou, 2014).

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The Witnesses are expected to live according to the Bible, conducting missionary work. The religion has strict rules that if one goes against any of them they are disfellowshipped. For example, if one attends any other church such as Catholic, or Protestant. There is an also additional law regarding the kind of medical treatment they are to seek. If a witness receives blood or gives blood, they are to be dis-fellowshipped. When one is disfellowshipped, they are allowed to attend the Kingdom Hall services, but will not speak to anyone. In other words, they are treated as if they do not exist even with their closest family. Despite their beliefs, the Witnesses believe in earthly leadership and since it is for Satan. However, the witnesses do not are not servicemen in the military, pledge allegiance to the flag, rally for political leadership in the Unions of labor.

In health, perspectives the Jehovah witnesses are people with strong religious beliefs and do not prescribe to some forms of medical treatment. Since its inception, the religious beliefs of the Jehovah witnesses have placed emphasis on preaching rather than healing and illnesses. Even when the Millennium approached, they believed that all earth problems will come to an end especially those related to health would find a solution. To them mental illnesses, exist because people believe that they exist, it is for this reason that the Witnesses believe that half of the world’s population suffers from mental illness.

The beliefs of the Jehovah witnesses are drawn from the Bible. Therefore when approaching healthcare, the Jehovah witnesses are always determined not to go against the commandments of God. They take into consideration the biblical teachings of life both in spiritual and physical health aspects. Most of these stereotypic beliefs are drawn from their founder Russell, who believed that falling ill begun from Adam. Some of the beliefs include that Jehovah Witnesses should not operate hospitals like other Christian denominations because at some point one the founders Clayton Woodworth regarded the American Medical Association was an institution founded in ignorance and error. Additionally, Clayton as most of the staunch Jehovah witnesses does not vaccinate themselves and their family and regard vaccination as a violation of God’s laws. It was easy for these beliefs to spread since Clayton was the chief editor of the Golden Magazine that was simply a publication of his views and the official Watch Tower Publications. Despite these strong beliefs, most Witnesses of this age regard to respect for medical research, hospitals. In addition, some of them operate hospitals and are employed as physicians and doctors.

Introduction

Jehovah Witnesses’ rejection of blood transfusion is widely known, and they would rather let a family or friends die than allow transfusion or donate blood. They believe that blood is a source of life and if removed from the body even for storage is makes it dirty and should not be reused. Consequently, the members do not accept surgical procedures that involve taking away and storage of their own blood. In these beliefs children, the most affected ones since parents have the duty to make all medical decisions for their children. In addition, the members do not accept organ donation and can only accept a bloodless organ transplant. This paper shall begin by describing the beliefs of the Jehovah witness and their effect on the administration of healthcare. The paper shall then provide strategies for overcoming these beliefs and barriers to guarantee good health care for Jehovah Witnesses. The paper will have a recommendation and a conclusion section.

Jehovah Witnesses Healthcare Beliefs and how they impede receiving of Healthcare

The Jehovah Witnesses are primarily known to refuse a blood transfusion. According to the religious beliefs, one loses eligibility to enter paradise if they accept blood from another person or donate blood. Most Jehovah Witnesses carry with them a medic alert card that has instructions that prohibit blood transfusion. Additionally, they refuse healthcare procedures that may necessitate blood transfusion, for instance, heart surgeries. However, some of their members have the choice of deciding whether to accept blood or not. The law allows any adult to refuse a blood transfusion, however for children this decision is usually left to their parents and guardians. Therefore, most children from Jehovah Witness families are very likely to die since their parents will not allow blood transfusion or surgeries that may require a blood transfusion. Such incidences prompt the hospital to seek the intervention of the court to save the life of a child. The situation is usually worse if it does not reach the court in time. The blood transfusion belief is usually at the heart of most Jehovah witnesses’ families, and the conflict arises when the medical practitioners are concerned with how to manage their healthcare.

Jehovah Witnesses believe that life begins at conception. Therefore, medical procedures such as abortion are not permitted, even when the life of a mother is in danger. Since life begins at conception, terminating, a pregnancy is a sin according to the Holy Bible. Therefore, the witnesses believe that the life or right of a mother is not to be questioned to pave the way for abortion. Every pregnancy is God’s will. In one of their famous publications, Awake, abortion should not be used to control birth since it is against God’s Commands.

Another medical belief related to blood transfusion is the managing the health of pregnant women. It is a normal medical condition that some pregnant women would require additional blood for their safety and that of the baby. However, Jehovah witness pregnant women are known to decline blood transfusion even when it is threatening their lives. To Jehovah, witness blood represents life and should not be transfused.

The religious beliefs of Jehovah Witnesses do not permit them to donate their organs. They say that organs contain blood and that the Bible prohibits sharing of blood and would not let any other person’s blood flow in theirs. They also do not agree to organ transplantation unless it is on the bloodless basis. Therefore, they would advise their doctors to conduct surgery where it does not involve sharing of blood. In this case, the patient is prepared early enough, for example giving them vitamins and foods that will increase their blood content.

Sterilization is also prohibited in the Jehovah Witness religious beliefs. No reference is drawn from the Bible, however; their argument originates from an ethical perspective. They argue that if one is sterilized, they may likely change their mind and want to have children. They say that sterilization is a threat to the institution of marriage. Closely related to sterilization is contraception. The Jehovah Witness organization advice its members against accepting any contraceptive. They argue that our bodies are the temple of God and taking contraception is interfering with God’s work. To add on, they argue that contraception sometimes results in abortion, which is prohibited, in the Bible.

Surrogacy is condemned by the religion, whether one is impregnated by artificial insemination or by an embryo of the married couple. Artificial insemination and the surrogacy procedures are regarded as an abuse of marriage and matrimonial bed. Artificial insemination by an unknown donor is explained as a form of adultery.

How to overcome the health care barriers/ Beliefs

Children belong to the State, and that is the duty of the Federal Government to ensure the health of such children. Parents have a role to play in ensuring their child receives proper medical care; however when they fail to perform this role the state is supposed to interfere to save the life of a child. Members of the Jehovah witness do not allow certain medical procedures for their family. For example, as explained earlier blood transfusion is prohibited and if a terminally ill child is need of blood the decision is left to the parents. For fear of being unfellowshipped, the parents always choose not to allow blood transfusion or let their child undergo surgery requiring a blood transfusion. To overcome these challenge courts have always been called upon to rule whether or not the child should undergo the treatment. However, sometimes the decision of the courts may take a longer time. Therefore, the state should pass legislation to allow hospital superintendent to allow this treatment especially about protecting the life of a child. Members of the Jehovah Witnesses do not accept blood transfusion in accordance with their religious beliefs. However, they still want quality medical care that does not use blood transfusion procedures. Situations of medical emergencies are prone to the need to conduct blood transfusion to save the life of a patient. In particular, they refuse transfusion of blood and all blood components. It is upon the Jehovah Witness patient to decide whether to accept a blood transfusion. The religion, however, specifies various solutions, for instance, it suggests the use of normal saline, dextrin, lactated Ringer’s Solution for Jehovah Witness patients. To reduce blood loss and increase the necessity for a blood transfusion the religion advises on the use of desmopressin and aprotinin.

To ensure all the rules concerning healthcare are observed the Watchtower has created several Hospital Liaison Committees in most hospitals to ensure that the patient’s requests are respected. Since most Witnesses do not accept a blood transfusion, it is a hard task for doctors and physicians in managing such patients. Doctors, therefore are forced to understand such patients to avoid legal actions. Doctors would opt for erythropoietin combined with iron supplements that enhance hemoglobin synthesis.

Finding medical solutions to blood transfusion is an effective way of managing the health of Jehovah Witness patients. According to Partovi et al., doctors must respect the wishes of the patients and seek alternative treatment methods. In their papers, further, the hospital provides a case study of a 57-year old witness patient who was diagnosed with anemia. In their research, they recognize the United States Food and Drug Administration approved that Human erythropoietin for the treatment of anemia that is associated with chronic renal failure. They explain that erythropoietin has amino acids that stimulate the production of red blood cells. Additionally, zidovudine therapy has been approved by the Food and Drug Administration of the United States for the treatment of patients with immunodeficiency virus infection, anemia, and cancer therapy. Fortunately, the Witnesses have approved the therapy as an option for blood transfusion. In the case study, we learn that it is possible to treat an anemic patient with a hemoglobin level lower than 7.5 g/DL (Partovi et al., 2013)..

For religious reasons, Jehovah Witnesses do not accept blood transfusion but accept organ transplantation. Various medical scholars have researched on how to conduct bloodless organ transplants. For example, research on a bloodless liver transplant protocol. The research conducted on Jehovah Witness patients that first underwent erythropoietin and iron therapy, which increased their Haematocrit. Seven of the patients underwent total liver transplant using the continuous circuit cell saving system and high dose aprotinin. The surgery transplant was successful since all the patients received no blood during the procedure. From the research, we find that it is possible to carry out bloodless transplant or use the patient’s blood for successful surgical procedures. The doctors were able to reduce the intraoperative need for blood products since the patients were prepared earlier for the surgery. Such procedures help in overcoming the blood transfusion barrier among Witness patients (Partovi et al., 2013).

Recommendations

This section shall provide a number of strategic recommendations on how to overcome the health challenges posed by Jehovah Witness patients. It is the constitutional right of every person to refuse unwanted medical therapies regardless of whether the decision is in line with the doctor’s medical judgment. This right to reject treatment may be exercised by the patient directly or a parent over their child. This, therefore, means a Jehovah Witness patient who clearly states that they do not want a blood transfusion, and then the physician is expected to honor this wishes even in the face of a life-threatening hemorrhage. However, in cases of medical emergencies such as treatment of sexually transmitted illnesses among minor, physicians are protected from legal action if they decide to treat a Jehovah minor. Additionally, the state is allowed to step in if the life of a minor is in danger and the only solution is for such a minor to undergo a blood transfusion.

Some states have enacted a law that allows the medical physician to treat a child or minor without the parents or guardians permission. For instance, the State of North Carolina has allowed the treatment of minors without the parents in several circumstances. For example, sexually transmitted diseases, drug abuse, pregnancy and emotional disturbance. In addition, the laws of North Carolina do not allow parents not to treat their children based on their religious beliefs. In addition, 41 states provide the exception religious beliefs, especially in child abuse cases. The department of child services is also allowed to step in and take custody of the minor if the minor is in need of medical attention, (Lindholm, 2012).

I would recommend that medical practitioners seek assistance from others in case they faced with a conflict of treating a Jehovah witness minor. In addition, they should make use of the Hospital Liaison Committees set by the Jehovah witness to oversee that the Jehovah Witness patient’s religious beliefs are not threatened.

Furthermore, more states should enact laws that protect physicians from liability in case they decide to save the life of a minor by conducting the prohibited health procedures by the Jehovah witnesses. A good example in the state of Carolina that has enacted a law that allows doctors to treat emergency medical treatment despite the parents or patients objections. The same law protects the doctors from legal action in case they choose not to honor the wishes of the parent or the patient. Such laws do not direct the action of the doctor but consider it a moral one.

Conclusion

Jehovah witnesses are very religious and follow their interpretation of the Bible to the letter. Any witness who goes against the health beliefs then they are likely to be dis-fellowshipped. Their religious beliefs are sometimes seen as a barrier to physicians when offering medical services. One of the major beliefs is that blood is life and should not be shared or transfused. It is for this reason that most Jehovah Witnesses carry with them special cards that would help the doctors know the medical procedures they would not need. In addition, there are Liaisons Committees set to ensure Jehovah Witnesses patients get the treatment they require. Jehovah Witnesses believe that organ transplantation is fine but if it involves the exchange of blood, then it should not be done. It is for this reason that most Witnesses would not undergo surgeries that may prompt blood transfusion.

There are also a growing number of bloodless surgeries that physicians are researching on; there are over hundred Medical Centers that offer this kind of treatment in the United States. Since Witnesses accept this kind of treatment, then they should not be subjected to blood transfusion surgeries since this is likely to affect their mental health. In addition, it is important to understand that the children of Jehovah Witness carry the most religious belief burden since they have mixed feelings between religious prohibitions and personal inclinations.

Communication between the patient and the medical doctor is very important to ensure that there is no conflict concerning the form of medical treatment. Recognition of the right and autonomy of every patient is the duty of every medical practitioner. For pregnant women who refuse a blood transfusion, it is important to the doctor in charge to plan alternative treatment that shall be used in the event of hemorrhage. The same applies to a patient who is supposed to undergo an organ transplant; such patients are supposed to be prepared earlier enough to ensure that no complication arises where they would be forced to need blood.

References

Agapidou, A., Vakalopoulou, S., Papadopoulou, T., Chadjiaggelidou, C., & Garypidou, V. (2014). Successful treatment of severe anemia using erythropoietin in a Jehovah Witness with non-Hodgkin lymphoma. Hematology Reports, 6(4), 73-74. doi:10.4081/hr.2014.5600

Lindholm, J., Palmér, K., & Frenckner, B. (2012). Long-term ECMO treatment in Jehovah’s Witness patient without transfusions. Perfusion, 27(4), 332-334. doi:10.1177/0267659112444328

Partovi, S., Bruckner, B., Staub, D., Ortiz, G., Scheinin, S., Seethamraju, H., & Loebe, M. (2013). Bloodless Lung Transplantation in Jehovah’s Witnesses: Impact on Perioperative Parameters and Outcome Compared With a Matched Control Group. Transplantation Proceedings, 45(1), 335-341. doi:10.1016/j.transproceed.2012.06.057

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Why Children of Illegal Immigrants Should Have Equal Educational Rights

by Herman Bailey | Feb 24, 2023 | Essays | 0 comments

Illegal immigrants refer to individuals who enter a country or nation without genuine permission of the country or violate the terms of their admission (Haugen 15). This document focuses deeply on a sided stand with reasons on why the children of illegal immigrants should have the same educational benefits as those of citizens. Todd Rosenbaum and Thomas Friedman elaborates on their reasons why the children of the illegal immigrants should be given same education rights lie the children pf the united states citizens. Todd Rosenbaum pointed out that lawmakers in different states have unsuccessfully tried in the past to ban enrollment of the children of the illegal immigrants in higher education institutions. Moreover, the majority of them are kept out of the universities and colleges because in-state tuition is not extended to them. Furthermore, this is compounded by the federal statutes that back these discriminatory clauses by forcing any state in extending any higher education benefits to illegal students. The paper will argue in support that children of the illegal immigrants in the United States should be given the same rights in education as the children’s of the United States citizens.

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Children of the illegal immigrants just like any other child of the citizens of United States have a wealth of opportunities ahead of them which can only be achieved with good college degrees. By encouraging the readers to imagine that they are students in a university, Todd Rosenbaum, brings out the plight of the children of illegal immigrants (229). Because of laws, the children of the illegal immigrants are not allowed to attend public education institutions, and they are unable to afford the tuition fees too. This forces them to withdraw from schools and losing hope of ever achieving their dreams or getting the opportunities they dreamt of achieving one day. Therefore, these children should be given same rights in education as the children of the United States citizens such as access to educational loans, grants, in state tuitions among others. Just like Todd Rosenbaum, Thomas Friedman also begins his article by narrating a dinner party he attended where most of the 40 finalists in the Intel Science Talent search 2010 were immigrants from Asia. From his narration, the reader gets to understand why children of the illegal immigrants in the United States should be given the same rights in education as the children of the United States citizens. They should be given the same opportunities in education to attract and retain them in an orderly fashion. This way, there would be a mix of high aspiring and energetic people and this result into a world intellectual and aspirational first draft choices. He further suggest that by keeping a constant flow of immigrants into the country is the key to the United States in keeping ahead of China. This is because magic happens when there is a mix of all high aspirational and energetic people in a free market and democratic system (237).

Illegal immigrants also pay taxes like other citizens of United States therefore should also be given equal education rights like the children of the United States citizens because. According to Santana, Institute on Taxation and Economic Policy (ITEP) indicated that the illegal immigrants collectively paid in 2010 an estimated $10.6 billion to local and state taxes. For instance, they paid more than $2.2 billion in California, $2 million in Montana (1). Averagely, from their income they pay 6.4% as taxes. Similarly, Congressional Budget Office (CBO) report in 2007 documented that that 50%-75% of the 11 million illegal immigrants in United States file and pay every year their income taxes (para 4).

The children of the illegal immigrants had no role or say in their destinies and therefore it is unfair to discriminate them by denying them educational rights. Some people will argue that why should benefits be extended to the people who have chosen to ignore the country’s immigration laws. But again, it is factual that most of these children of illegal immigrants did not make the choice of immigrating to the United States on their own. Todd Rosenbaum used an example of the commonwealth of Virginia. Few lawmakers in Virginia are applying all their effort to ensure that it is difficult for the children of the illegal immigrants to enroll in public universities and colleges in Virginia. Their chances of improving their situations are limited because in-state tuition is not extended to them. Moreover, the majority of them are barred from attending these higher education public institutions because they cannot afford it (Rosenbaum 230). The paper believes that the children of the illegal immigrants should not be discriminated by the lawmakers because of the decisions of their parents. Instead, the lawmakers should lay more emphasis on helping these young children of the illegal immigrants to acquire legal status. This also implies affording these children opportunities that will enable them to develop as responsible and productive society members. Thomas Friedman tells his story about his chat with Amanda Alonzo, a biology teacher who taught two of the finalists. Alonzo pointed out that her secret was the supportive resources from the school, grants from Intel and the supportive parents. If this could be copied by the governments, then more bright and innovative Intel finalists could be produced (237).

The supreme case ruling of 1982 that ensured that all people living in the United States should attend public and secondary schools with no regard to their legal status. Most of these students who are the beneficiary of the decision graduated from the public high schools, and were cable of even excelling in universities and colleges but unable to afford. With such educational progress, returning to their home countries is not a viable option but they should be assisted by the governments to pursue their higher education and realize their dreams (Rosenbaum 230). The argument for supporting equal educational rights is further supported by an argument by Thomas Friedman that the most important economic competition in today’s world is no longer about companies or countries, but between a person and his or her imagination. Therefore, discriminating against the illegal immigrants’ children because of their country of original in today’s world is not healthy. They should be supported and offered equal educational rights just like the United States citizens children. What the children imagine, they can act on them faster, cheaper and farther than ever before (Friedman 237).

Work cited

Rosenbaum, Todd. ‘Educating Illeal Immigrants’. Cavalier Daily 2006: 229-231. Print.

Friedman, Thomas. “America’s Real Dream Team.” The New York Times. The New York Times, 20 Mar. 2010. Web. 1 Nov. 2015.

Haugen, David M, and Susan Musser. The Children of Undocumented Immigrants. N.p., 2013. Print.

Santana, Maria. ‘5 Immigration Myths Debunked’. CNNMoney. N.p., 2015. Web. 7 Nov. 2015. < http://money.cnn.com/2014/11/20/news/economy/immigration-myths/ >

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

TThe Impact of Gender Roles in August Wilson’s Fences

by Herman Bailey | Feb 24, 2023 | Essays | 0 comments

The play Fences, by August Wilson, is a story of a troubled African-American family living in the 1950s. Focusing on the plight of the Maxsons, a family comprised of a faithful wife (Rose), unfaithful husband (Troy), hardworking son (Cory), lazy son (Lyons) and mentally handicapped brother (Gabriel), Fences explores their lives in an attempt to show some of the trials African-American families faced during the 1950s. The central plot of the play concentrates on Troy Maxson, the alcoholic, cheating husband who is stuck living in his past baseball glory days, and his attempt to earn a living and be a successful father. Although the play revolves primarily around Troy, Troy’s wife Rose is arguably just as important to the purpose of the play, if not more. Hossein Pirnajmuddin and Shirin Sharar Teymoortash make the argument that the “spaces” in the fence Troy Maxson constructs around his house throughout the play are a metaphor for the different geographical, historical, socio-economic, racial, political, psychological, and linguistic ‘spaces’ that exist between the Caucasian and African-American people of the time period. While Pirnajmuddin and Teymoortash make a good point in pointing out the different ‘spaces’ separating the races, I believe they left out a particularly important ‘space’; gender. Gender is a ‘space’ in the play that even separates those of the same race. While Troy does experience many hardships due to his race, Rose’s aspirations were limited even more by her gender, a gender that prevented her from even considering the limited opportunities that Troy had.

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• Symbolic Boundaries in My World

Rose’s gender ultimately determines what she can and cannot do. In the 1950s, women were restricted to domestic activities such as raising families and housekeeping. Due to the social idealogy in that period, it would be seen as strange for Rose to have a profession like the men did. Author Sheri Metzger writes in her critical essay “An Essay on Fences” that “women were restrained by traditional roles and the division of private and public spheres… women primarily functioned in the private sphere of home and domestic chores” (Metzger 1). It is this social mindset that creates a ‘space’ prohibiting Rose from ever doing more than being a housewife. This role that has been set for Rose is evident in the play when she attempts to talk to Troy while he is speaking with a friend and he simply tells her to leave, saying that “this is men talk” (Wilson 1027). By telling her that she is not allowed to talk with them, Troy is further demonstrating that Rose is merely an object, one not nearly important enough to talk to when other things are going on. Unfortunately for Rose (and all women of the 1950s), Troy’s opinion that women are unimportant is held by almost all of the male population, making it impossible for Rose to do anything more than be a housewife.

Rose’s gender forces her to stay in her role of a housewife. In Joseph Wessling’s article “Wilson’s Fences” Rose is described as a person who “personifies unconditional love” (Wessling 124). While this may be true, Rose’s gender gives her no choice but to accept whatever circumstances arise. This is because women of the 1950s were expected to side in favor of their families and husbands, even if their personal opinions differed. Rose tells Troy that at the beginning of their marriage she “took all [her] feelings, [her] wants and needs, [her] dreams … and [she] buried them inside [him]” (Wilson 1062). She is telling Troy and the audience that whatever dreams or aspirations she had were ‘buried’ away when she married Troy. As a wife, Rose’s new responsibilities were focused solely on raising a family and helping Troy. This expectation that a woman should be no more than a housewife leaves a huge gender ‘space’ in the play prohibiting Rose from striving for a better and more successful life.

Rose is forced to accept and excuse Troy when he announces that he has been cheating on her. She does not do this because she loves Troy, because she basically has nowhere else to go. In “Space in August Wilson’s Fences,” Pirnajmuddin and Teymoortash point out how August Wilson “deftly conflates two images, that of an unrepaired fence and that of Troy on the verge of physical and mental breakdown” Pirnajmuddin and Teymoortash 45). The unrepaired fence in this statement represents the irreparable damage Troy has caused to his relationship with Rose. In today’s society, if a women were to come home to a cheating husband and a bastard child, it would be perfectly fine (perhaps even recommended) if she were to divorce him and start anew. For Rose and fellow skeletal muscles. In a study conducted by (), the findings indicated that HRT improves the functions of muscles in women of the 1950s, the same cannot be said. Because of her gender, she must fulfill the role of ‘loving housewife’ that society has set up and stay with Troy. The article also speaks of Troy on “the verge of physical and mental breakdown” (45). If Troy is unable to cope with the ordeal, how must Rose feel about it? After all, it was Troy who had the affair which resulted in a baby, not Rose. If Troy was unable to handle all of the stress that accompanies the predicament he put himself in, Rose must feel even worse. However, she must carry on and fulfill the role her gender gives her or suffer the consequences of being out of the norm. It is this huge gender ‘space’ that forbids Rose from going after what she wants in life and forces her to be a wife who forgives her husband for all of his wrongdoings.

Rose is forced to assimilate into her non-subjective role as a woman. As stated earlier, the role of a woman in the 1950s was merely to be a model housewife and mother. Although skeletal muscles. In a study conducted by (), the findings indicated that HRT improves the functions of muscles in women were allowed to express their opinions, very seldom were they actually considered. This was due to the social standard of the time that men were the ones responsible for making important assessments and decisions for their families. Leslie Orr states in her essay “Gender Role Strain in Selected Plays by August Wilson” that “society expects males to perform well in these roles to be deemed a man” (Orr 1). When Rose is mad at Troy and tells him that he should’ve “stayed in [her] bed” (Wilson 1062), Troy simply continues talking about why having the affair made him feel good. He didn’t seem to care about Rose’s emotions at that point, he was simply interested in justifying the affair, telling her that he’d been “standing on first base for eighteen years” (Wilson 1062) and that he was pretty much bored with her. Rose is unable to voice her opinion effectively in the argument because Troy won’t let her. He is the ‘big man’ of the house and she basically has to accept what he says about the affair. It is this unwilling acceptance due to gender that disallows Rose to make any important decisions or voice her opinion.

Space in August Wilson’s Fences is much more than a simple gap in a fence post. It represents the geographical, historical, socio-economic, racial, political, psychological, linguistic, and gender spaces that minorities in the 1950s had to face. It is the gender ‘space’ that prohibits rose from ever following her dreams or achieving her desires. Because of the gender ‘space’ prevalent in the 1950s, “there is less opportunity for Rose to escape the pressures and responsibilities of life” (Metzger 1). The gender ‘space’ in Fences is arguably the most important boundary in the play, and is responsible for many of the hardships the Maxson breast cancer. Ann has been a staunch Christian since childhood just like the rest of her family goes through.

Works Cited

Metzger, Sheri. “”An Essay on Fences.” Drama for Students. Detroit: Gale. Literature Resource Center. Web. 21 Apr. 2013.

Orr, Leslie. “Gender Role Strain in Selected Plays by August Wilson.” ProQuest Dissertations and Theses. Ann Arbor, Michigan. 1997. Print.

Pirnajmuddin, Hossein, and Shirin Sharar Teymoortash. “Space in August Wilson’s Fences.” Studies in Literature and Language 3.2 (2011): 42+. Literature Resource Center. Web. 21 Apr. 2013.

Wessling, Joseph H. “Wilson’s Fences.” Explicator 57.2 (Winter 1999): 123-127. Rpt. in Contemporary Literary Criticism. Ed. Jeffrey W. Hunter. Vol. 222. Detroit: Gale, 2006. Literature Resource Center. Web. 21 Apr. 2013.

Wilson, August. Fences. Backpack Literature: Second Edition. Ed. X.J Kennedy, Dana Gioia. New York: Pearson Longman, 2008. 1024-1079. Print.

Herman Bailey

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