Passive smoking almost doubles the risk of the progressively degenerative eye disease, age related macular degeneration, shows research in the British Journal of Ophthalmology.

The macula lies at the centre of retina at the back of the eye. It’s crucial for fine central vision, which is essential for tasks, such as reading and driving.

The risk of macular degeneration increases once someone is over the age of 60. It is a leading cause of partial sightedness and blindness in many European countries and the USA.

The researchers base their findings on 435 people with end stage macular degeneration and 280 partners who lived with them.

They found that the more a person smoked, the greater were their chances of developing age related macular degeneration, and the results showed that it was the amount smoked rather than whether someone had ever smoked that was critical.

Regularly smoking a pack or more a day for 40 years almost tripled the risk of age related macular degeneration compared with those who did not smoke, the research showed.

Smoking increased the risk of both types of macular degeneration (geographic atrophy and choroidal neovascularisation).

Giving up for 20 years or more cut the risk to levels comparable with those for non-smokers, the research found.

The risks were also increased for partners who were non-smokers, and had lived with a smoker for five years or more. Their risk nearly doubled.

Smoking and age related macular degeneration: the number of pack years of cigarette smoking is a major determinant of risk for both geographic atrophy and choroidal neovascularisation Br J Ophthalmol 2006; 90: 73-80

Emma Dickinson
edickinsonbmj
BMJ Specialty Journals
bmj

The recent H1N1 pandemic has highlighted the importance of identifying public health measures which can help to mitigate flu virus transmission. Researchers conducted a prospective cluster-randomized trial to test whether improved hand hygiene or surgical face masks could reduce the spread of flu within households.

The researchers studied 407 people with flu-like symptoms who visited one of 45 outpatient clinics across Hong Kong within 48 hours of symptom onset, had rapid tests that confirmed infection with influenza A or B, and lived in a household with at least two other individuals, none of whom had reported flu symptoms in the preceding 14 days. The flu patients plus their household members were randomly assigned to one of three groups: control, control plus enhanced hand hygiene, and control plus enhanced hand hygiene plus face masks.

The researchers found that hand hygiene and face masks appeared to be effective at preventing household transmission of the flu virus only when implemented within 36 hours of symptom onset. These findings have important public health implications, as they suggest that non-pharmaceutical interventions can reduce flu transmission if implemented early after symptom onset.

Source:
Angela Collom
American College of Physicians

Massachusetts Gov. Mitt Romney (R) on Thursday said the state’s newly adopted restrictions on human embryonic stem cell research are intended to prevent an “Orwellian” future, Reuters reports (Reuters, 8/31). The Massachusetts Public Health Council on Tuesday adopted new regulations on embryonic stem cell research that Harvard University and several state research centers and hospitals say could expose scientists to criminal penalties for conducting certain research activities. The new regulations affect a state law (SB 2039), which took effect after the state Legislature overrode a veto by Romney, that allows human cloning for research purposes and bans human cloning for the purpose of reproduction. The regulations prohibit creating a fertilized embryo with only the intent of “using” the embryo, while the law prohibits creating fertilized embryos with only the intent of “donating” the embryo. Opponents of the regulation said that the state Legislature did not intend for the change because the new prohibition applies to scientists. Paul Cote, state public health commissioner, on Wednesday said that the new rules were created through an “active dialogue” with Romney’s office and that the Department of Public Health was tasked with eliminating what Cote described as “loopholes” in the law (Kaiser Daily Women’s Health Policy Report, 8/31). Romney on Thursday said he believes that creating embryos for the purpose of research “crosses a very bright moral line to take sperm and egg in the laboratory and start creating human life” (Nichols/Ryan, Boston Globe, 9/1). He added, “In laboratories, you could have trays of new embryos being created” (Johnson, AP/Metro West Daily News, 8/31). Romney said he supports research on embryos taken from fertility clinics but not on cloned embryos research (Boston Globe, 9/1). B.D. Colen, a Harvard spokesperson, said the MPHC regulations are unnecessary, adding that Romney seems to be using the state health department to “accomplish what he was unable to accomplish through the legislative process” (AP/Metro West Daily News, 8/31).

“Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

The Australian Nursing Federation (ANF) has called on the Federal Government to urgently review the Productivity Commission’s draft report in to the aged care sector.

ANF federal secretary, Lee Thomas, said the report – Caring for Older Australians – failed to address vital issues surrounding quality care needed for elderly Australians and their families.

“We are urging the Federal Government to firstly review the report and its draft recommendations, and then intervene, to ensure that aged care residents, their families and hard-working nurses and assistants in nursing are simply included throughout the reform of the sector,” Ms Thomas said today.

“It is crucial that any decisions made around the reform of the aged care sector must take into account the care needs of elderly residents.”

Ms Thomas said the report did not recognise several crucial workforce issues including the requirement of minimum care hours for the delivery of quality care and that extra staffing levels and the right skills mix are integral to improving care for older Australians, many of whom are experiencing more complex health needs.

She said there was also a need to recommend the licensing of all workers in the aged care sector – something missing in the report.

“As an ageing population, Australians want to be assured that when they reach an age of reliance and require care, the system will look after their health and care needs.

“The draft recommendations in the report fail to offer any assurances of this nature, which is a real concern to the ANF.

“We had hoped the Productivity Commission would make recommendations that would improve the lives of aged care residents and the staff who care for them, but the fact is the report has paid little regard to the issue of care delivery.

“Instead, it has promoted deregulation of the sector. Whilst we believe that financial reform is necessary, there is no point of access if there are no nurses or assistants in nursing to care for people once they enter a nursing home or require care in their homes.”

Ms Thomas said the ANF would be seeking urgent meeting with the Federal Minister for Ageing, Mark Butler, to discuss its concerns about the report.

Source:

Australian Nursing Federation (ANF)

Biomagnetics Diagnostics Corp. (Pink Sheets:BMGP), a developer of revolutionary diagnostic systems and technology for malaria, HIV/AIDS, hepatitis, tuberculosis and detection, announced today the implementation of a program to accelerate the availability of the world’s first Integrated Optical BioSensor (IOBS) platform. The Company is currently reviewing research and manufacturing partnerships to develop simple to replicate bench top versions of the IOBS platform on which single pathogen or multiple pathogen testing assay cartridges can be developed. This strategy is expected to significantly accelerate the availability of this life and cost saving technology.

The Company’s initial strategy was to fully produce the handheld version of the IOBS platform and to then use that platform to develop all of the many different types of pathogen testing assay cartridges. By taking a slightly different direction and developing desktop versions of the IOBS platform, which can be produced more quickly, the Company will be able to develop the single test assay cartridges for malaria, cholera, human tuberculosis, bovine tuberculosis and HIV/AIDS in parallel to the production of the handheld units. This approach will significantly reduce time-to-market and make this important technology available to the world much sooner and will allow the corporation to accelerate its revenue growth rate.

“It is important for us to accelerate assay test cartridge development as we are currently scheduling our malaria clinical trial with one of the most prestigious malaria research institutions in India with additional trials being organized in Kenya and Mexico,” commented Clayton Hardman, CEO of Biomagnetics Diagnostics Corp. “We are very anxious to begin demonstrating this technology in real world settings as we believe we will be able to lower the cost of malaria, tuberculosis, cholera and HIV/AIDS testing to unprecedented levels while at the same time reducing the time it takes to receive results from days or hours to a matter of a few minutes. While we believe the production of this device will yield significant returns for our shareholders, and this is clearly an important priority, we have never lost sight of the fact that there are tens of thousands of lives we may be able to save through our important endeavors in this area.”

Source
Biomagnetics Diagnostics Corp.

Our bodies are perfectly capable of renewing billions of cells every day but fail miserably when it comes to replacing damaged organs such as kidneys. Using the flatworm Schmidtea mediterranea-famous for its capacity to regrow complete animals from minuscule flecks of tissue-as an eloquent example, researchers at the Stowers Institute for Medical Research demonstrated how our distant evolutionary cousins regenerate their excretory systems from scratch.

In the process, the Stowers team led by Howard Hughes Medical Institute and Stowers investigator Alejandro SanchГ©z Alvarado, Ph.D., not only established flatworms as a valuable model system to study tissue maintenance and organ regeneration but also provided new clues about the evolutionary origin of mammalian kidneys. Their study is published in the current issue of the journal Development.

“The past ten years of planaria research have shown that planarians use pretty much the same molecular toolkit for building their bodies as other animals,” says first author Jochen Rink, Ph.D., formerly a postdoctoral researcher in the SanchГ©z lab and now a group leader at the Max-Planck-Institute of Molecular Cell Biology and Genetics in Dresden, Germany. “Because of this fundamental similarity between all animals, understanding how a worm assembles its excretory system may very well be relevant to understanding kidney physiology and regeneration in humans,” he adds.

Most animals studied in the lab fall within two main branches on the evolutionary tree of life: mice, rats, and salamanders are part of the vertebrate lineage, while fruit flies and the roundworm Ceanorhabditis elegans belong to the lineage encompassing molting animals. “People have drawn conclusions about the evolution of certain attributes by looking exclusively at these two branches,” says SanchГ©z Alvarado. “That’s akin to trying to work out your family tree but ignoring your entire maternal lineage.”

In contrast, flatworms, also known as planaria, are part of a branch that has been largely ignored by modern molecular biology. “The so called lophotrochozoa are an incredibly large and diverse group of animals we know very little about,” explains SanchГ©z Alvarado.

What was known is that-unlike fruit flies and C. elegans-planaria possess very complex excretory systems akin in many respects to mammalian kidneys. “Planarian protonephridia are so far the only invertebrate model system that combines pressure filtration with filtrate modification similar to mammalian nephrons, the basic functional unit of the kidney,” explains Rink. Their anatomy, however, was not well understood.

When Rink and co-first author Hanh Thi-Kim Vu, Ph.D., a graduate student in the Sanchez Alvarado lab, analyzed their structure with the help of electron microscopy, the scientists found that planarian protonephridia are complex epithelial organs that organized in a consistent and hierarchical manner: a distal tubule branching out into proximal tubules, each of which is topped by a ciliated flame cell – so named because under a microscope the beating of the cilia resembles a flickering candle.

But more importantly, they noticed that the endothelia forming the tubules are composed of a fixed succession of different cell types along their length reminiscent of the mammalian condition. “This suggests to us that the mammalian kidney originated before the branches split,” says SanchГ©z Alvarado. “The homologous structures in fruit flies and C. elegans diversified and diverged till they no longer resembled their common ancestor.”

Protonephridia are distributed throughout a flatworm’s body. To study their development researchers could simply cut the animals’ heads off and watch how they regrew the missing body part including excretory tubules within a week. They found that protonephridial tubules originated from a precursor structure, which undergoes extensive branching morphogenesis, the same process that also shapes vertebrate organs such as lung, kidneys or mammary glands.

When Rink interfered with the expression of EGFR5, short for epidermal growth factor receptor, during the regeneration process protonephridia could no longer undergo branching morphogenesis. If he did the same in non-regenerating planaria, they were unable to maintain the structural integrity of their protonephridia, which told him that under normal conditions the organ is constantly maintained through cell renewal.

“We take it for granted that we go to bed with two sets of fully functional kidneys and that we wake up with them the next morning but we don’t understand the fundamental processes that give rise to this very well choreographed maintenance of an organism’s form and function,” says SanchГ©z Alvarado. “We can now start to use planaria as a model to begin to understand how an adult animals maintain their form and function over a very long time.”

The work was funded in part by the Howard Hughes Medical Institute and by the National Institutes of Health, National Institute of General Medical Sciences.

Homeowners whose houses are flooding with the recent heavy rains should take extra precautions if they suffer from allergies or asthma, say allergists.

During a flood cleanup, indoor air quality in the home may appear to be the least of the problems. However, failure to remove contaminated materials and to reduce moisture and humidity can present serious long-term health risks. Standing water and wet materials quickly lead to, among other things, mold growth, to which many are allergic. The symptoms of mold allergy are very similar to the symptoms of other allergies and asthma, such as sneezing, itching, nasal discharge, congestion and cough and wheezing.

“One of the biggest issues homeowners will face is what to do about flooded carpeting,” said allergist James L. Sublett, MD, chair of the indoor environments committee for the American College of Allergy, Asthma and Immunology (ACAAI). ” The pads cannot be dried out and should be thrown away. Carpets should be pulled up and thoroughly dried within the first 24 hours. In addition, wall board damage will be hidden and if it has become wet, it should be replaced to above the water line.”

The Environmental Protection Agency recommends wearing an N-95 respirator mask while cleaning, in addition to goggles, gloves, long pants, long-sleeved shirts and boots or work shoes. Anything that was wet but cannot be cleaned should be thrown away. They also remind everyone to use place portable generators outside and far away from homes in order to avoid breathing in the carbon dioxide.

Source:
American College of Allergy, Asthma and Immunology (ACAAI)

September 9 is National Grandparents Day, a day to honor grandparents across America as important members of our families and communities. Grandparents play important roles in life, including that of guardian, comforter, and mentor. As they get older, however, several aspects of their lives change, including their sleep patterns. While older adults need about seven to eight hours of sleep each night, many often get less sleep, which may make them more susceptible to health problems.

“As we get older, our sleep is more easily disturbed,” says James P. Krainson, MD, of the South Florida Sleep Diagnostic Center in Miami and a spokesperson for the American Academy of Sleep Medicine (AASM). “Underlying health issues are often the cause of these disturbances. Arthritis and pain can cause frequent awakenings and interfere with falling asleep. Cardiovascular, neurologic, urologic and psychologic disturbances can likewise play havoc with our sleep. In fact, most all medical problems can disturb our sleep, and the older adults’ sleep is most vulnerable.”

Many older adults often have more trouble falling asleep than persons in other age groups. A study of adults over the age of 65 found that 13 percent of men and 36 percent of women take more than 30 minutes to fall asleep.

There are many other possible explanations for changes in older adults’ sleep patterns, says Dr. Krainson. Older adults may produce and secrete less melatonin, the hormone that promotes sleep. They may also be more sensitive to changes in their environment, such as noise, and this may cause them to awaken. Further, older adults may also have other medical and psychiatric problems that can affect their sleep, says Dr. Krainson, adding that researchers have noted that people without major medical or psychiatric illnesses report better sleep.

Several studies that outline the negative consequences of bad sleep among older adults were presented at SLEEP 2007, the 21st Annual Meeting of the Associated Professional Sleep Societies, this past June:

пЃ® Cognitive behavioral therapy successfully improves both immediate and long-term self-reported sleep and pain in older osteoarthritis patients. This demonstrates that improving sleep can be “analgesic” in older osteoarthritis patients, and that techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain-states.

– Regular aerobic exercise, combined with sleep hygiene education, improves sleep and quality of life in older adults with chronic insomnia.

– Untreated sleep complaints may pose a risk for falls.

– Older adults who reported engaging in shorter and less frequent naps during the day also reported spending more time asleep at night. Such older individuals also experienced more sleep time and slept more efficiently at night.

– A sleep-related breathing disorder may be associated with impairments in cognitive function in older men.

– Objectively determined estimates of short sleep were strongly related to obesity in older men and women.

Dr. Krainson notes that several studies published in recent issues of the journal SLEEP have some interesting findings about older persons and sleep:

– The effects of insomnia are different in older and younger people. While associations between insomnia and separated, divorced or widowed marital status were strongest in younger age groups, longer bouts with insomnia were more common in the older population, who are also more likely to be taking types of sedatives that have particular problems with addiction and side effects.

– As sleep quality and quantity typically decrease with age, objectively measured differences in the amount of sleep a healthy older man gets can affect his level of testosterone in the morning.

– A brief behavioral treatment for insomnia appears to be a promising intervention for older adults who suffer from insomnia.

According to Dr. Krainson, some of the more common sleep disorders in older adults include:

– Insomnia affects almost half of adults 60 and older.

– Obstructive sleep apnea (OSA) can elevate the risk for high blood pressure, stroke, heart disease, and cognitive problems. Snoring, a symptom of OSA, is a very common condition affecting nearly 40 percent of adults, and is more common among older people.

– Restless legs syndrome, where one experiences uncomfortable feelings in the legs, affects more than 20 percent of people 80 years and older.

– Periodic limb movement disorder, a condition that causes people to jerk and kick their legs every 20-40 seconds during sleep, is evident in almost 40 percent of older adults.

Not sleeping well can lead to a number of problems. Older adults who have poor nighttime sleep are more likely to have a depressed mood, attention and memory problems, excessive daytime sleepiness, more nighttime falls and use more over-the-counter or prescription sleep aids. In addition, recent studies associate lack of sleep with serious health problems such as an increased risk of obesity, cardiovascular disease and diabetes.

Despite obstacles many older adults have to overcome in order to get a good night’s sleep, Dr. Krainson says that it does not mean they are doomed to chronic sleep deprivation. While most people require seven to eight hours of sleep a night to perform optimally the next day, older adults might find this harder to obtain, says Dr. Krainson, adding that they must be more aware of their sleep and maintain good sleep hygiene by following these tips:

– Establishing a routine sleep schedule.

– Avoiding utilizing bed for activities other than sleep or intimacy.

– Avoiding substances that disturb your sleep, like alcohol or caffeine.

– Not napping during the day. If you must snooze, limit the time to less than one hour and no later than 3 p.m.

– Stick to rituals that help you relax each night before bed. This can include such things as a warm bath, a light snack or a few minutes of reading.

– Don’t take your worries to bed. Bedtime is a time to relax, not to hash out the stresses of the day.

– If you can’t fall asleep, leave your bedroom and engage in a quiet activity. Return to bed only when you are tired.

– Keep your bedroom dark, quiet and a little cool.

Dr. Krainson says that, although sleep patterns change as people age, disturbed sleep and waking up tired every day are not part of normal aging. Those who have trouble sleeping are advised to see a sleep specialist at a facility accredited by the AASM.

“Be prepared to tell the doctor how you spend your day and night, including your medicines, fluid intake and activities so that they will have all the information needed to decide how best to help you,” says Krainson.

For a listing of AASM-accredited facilities in your area, visit SleepCenters.

AASM is a professional membership organization dedicated to the advancement of sleep medicine and sleep-related research.

aasmnet

Working the night shift doesn’t appear to increase the risk of developing cancer, suggests the findings of a new study of Swedish workers.

Recent studies –and corresponding news headlines — have found that regularly working the night shift may increase the risk of developing breast, prostate and colon cancers. Some researchers say that the connection could be due to a decrease in the production of the hormone melatonin, as some animal experiments suggest that the hormone may have anti-cancer properties.

Our bodies produce their highest levels of melatonin at night, during sleep, but exposure to light at night suppresses melatonin production, said Judith Schwartzbaum, the study’s lead author and an associate professor of epidemiology at Ohio State University.

“However, the effects of melatonin on cancer development in humans are not well understood,” she said.

Schwartzbaum and her colleagues found no link between working the night shift and the risk of developing any kind of cancer. They came to this conclusion after analyzing nearly 20 years’ worth of data that compared people who reported jobs that required working during the day to people who said they had jobs that required night shift work.

The findings appear in a forthcoming issue of the Scandinavian Journal of Work, Environment and Health. Schwartzbaum conducted the study with researchers from the Institute for Environmental Medicine, located at the Karolinska Institutet in Stockholm, Sweden.

The study included all Swedish citizens who worked at least 20 hours a week in 1970, and who were included in both the 1960 and 1970 population censuses — a total of about 3.2 million people. The researchers gathered job information from each census.

They categorized the occupations according to the percentage of people who reported shift work: more than 70 percent, more than 40 percent, less than 30 percent, and no employees reporting shift work.

The researchers collected information on the people from 1971 through 1989 or until a worker was diagnosed with cancer or died.

Information about the cause of death came from the Swedish Cause of Death Registry. All cases of cancer that occurred within the study’s time frame were identified from the national Swedish Cancer Registry. Schwartzbaum said that all Swedish physicians who care for cancer patients must notify the national cancer registry when a patient is diagnosed with the disease.

To determine the percentage of night-shift workers in each job category included in the census, the researchers used additional occupational information from the Swedish Survey of Living Conditions conducted from 1977 through 1981. During this five-year stretch more than 46,000 workers were personally interviewed about their jobs and work schedules, including what hours during the day they worked. Schwartzbaum and her colleagues applied this information to the overall study group.

About 200,000 men and 100,000 women in the study developed cancer. There were roughly 2.1 million working men included in the census data, and about 1.1 million working women.

In the researchers’ main analysis, participants were categorized as either exposed or not exposed to shift work according to their occupation in 1970. The researchers followed both groups for 19 years.

In separate analyses, the researchers took the duration of night-shift exposure into account. They defined “exposure” as working in a job that met the criteria for night-shift work in both the 1960 and 1970 censuses.

“We identified occupations where many employees worked during hours that could affect the production of melatonin,” Schwartzbaum said.

Schwartzbaum and her colleagues defined shift work as work that had a rotating schedule with three or more possible shifts per day, or where the schedule included working between 1 and 4 a.m., which the researchers defined as working at night.

A very small percentage of the working population included in this study reported having jobs that met the definition of shift work (just 4 percent of men and 0.4 percent of women.)

For men, the main night-shift occupations included work in the paper manufacturing industry, working as a furnace operator and working as firefighters, policemen or train operators. The occupations of women who worked at night primarily included work as crane or hoist operators, delivery agents in the paper and publishing industries, or working as midwives.

The final results showed no relationship between shift work and an increased risk of developing prostate, colon or breast cancers or nearly any other kind of cancer, regardless of how much the occupation depended upon shift work.

Schwartzbaum points out that the current results don’t agree with a number of recently published studies, two of which found an increased risk of prostate cancer among rotating shift workers, and another half-dozen studies that suggested an increase in breast cancer risk among female shift workers.

“Many of these studies included very specific worker populations,” she said. “For example, studies of female flight attendants have found an increased risk of breast cancer and also a higher-than-expected risk for developing malignant melanoma.

“But airline workers differ from other shift workers due to their increased exposure to cosmic and solar radiation,” Schwartzbaum continued. “So it’s tough to tease out what exactly may contribute to their elevated risk of cancer.”

What’s needed, Schwartzbaum said, are large-scale international studies to help tease out the relationship between shift work and the risk of developing cancer.

“It seems like 3 million workers ought to be enough to get a firm idea of the risk, but it isn’t, especially considering the relatively low percentage of jobs that require shift work,” Schwartzbaum said. “We need studies that include data from multiple countries.”

###

Holly Wagner

Source: Judith Schwartzbaum

Ohio State University

A vaccine that is expected to eradicate the primary cause of meningitis epidemic in Africa is being used across Burkina Faso, starting today, December 6th 2010. If all goes well it will then be used across 25 African countries known as the “meningitis belt”. Group A meningococcus, for which this new vaccine is designed, accounts for approximately 85% of meningitis cases in those countries.

The vaccine is currently priced at $0.50 per dose. According to WHO (World Health Organization), it costs less that 10% of the $500 million typically needed to get a new vaccine developed and onto the market.

A partnership between PATH, an international non-profit organization and WHO created the Meningitis Vaccine Project which developed the new vaccine. WHO informs that its researchers worked closely with health authorities of the meningitis belt countries, as well as centers of excellent around the world.

An Indian company, which had agreed from the outset to accept technology transfer from companies with vaccine conjugation expertise, manufactures and sells the vaccine to African countries at low prices.

This month will see the start of nationwide vaccination campaigns in Mali and Niger. If a $475 million funding gap is met, WHO expects all 25 meningitis belt countries to be using the vaccine by 2015.
Meningococcal meningitis
This is a bacterial form of meningitis. Meningococcal meningitis is an infection of the lining around the brain and spinal cord – it is a serious infection. It is fatal in 50% of untreated cases.

People infect other humans through droplets of water either breathed or coughed out. Sneezing on somebody, or kissing them is also a possible form of human-to-human transmission. Those living in close quarters with an infected individual, or sharing their eating and drinking utensils might also become infected.

The incubation period – the time from initial infection to the appearance of first symptoms – can be from two to ten days.

Signs and symptoms may include a high fever, light sensitivity, headaches, a stiff neck, confusion, and vomiting.

Even with prompt and proper treatment, between 5% to 10% of patients do not survive.

Some survivors may suffer brain damage, learning disability and/or hearing loss.
The meningitis belt
The following countries form part of what is known as the meningitis belt:

Benin
Burkina Faso
Cameroon
the Central African Republic
Chad, CГґte d’Ivoire
Djibouti
Eritrea
Ethiopia
the Gambia
Ghana
Guinea
Guinea-Bissau
Kenya, Liberia
Mali
Mauritania
Niger
Nigeria
Senegal
Sierra Leone
Somalia
Sudan
Togo
Uganda

Source: WHO