World Heart Day 2009

The story "work with heart"

Over 17.2 million people die each year from cardiovascular diseases, making these the leading cause of death worldwide. Yet 80% of premature deaths from heart disease and stroke could be avoided by controlling the main risk factors: tobacco, unhealthy diet and physical inactivity.
Millions of productive life-years are lost annually, posing significant threats to the vitality of our highly-interdependent global system, especially in the context of the current financial crisis.

Businesses around the world, as well as leading organizations such as the World Health Organization and the World Economic Forum have recognized the importance of employee health to achieve core business objectives. Many have committed to include health promotion on their corporate agenda.

Yet it is mostly large corporations in developed countries that offer workplace health programmes.

There is an urgent need to extend these benefits to all employees, in other industries and sectors, and in other parts of the world. In particular, workers in low- and middle-income countries, where over 80% of deaths from cardiovascular disease currently occur, could benefit greatly from the implementation of such programmes.

Why Workplace Wellness?

As part of its commitment to the World Economic Forum initiative “Working Towards Wellness”¹, World Heart Day 2009 has been dedicated to this theme. Almost half of those who die from chronic diseases are in their productive years. The economic consequences - driven by productivity reduction and increase in costs caused by these diseases among workforces - are dramatic. The WHO estimates that between 2005-2015 income loss (in international dollars) could rise to as much as $558 billion in China, $237 billion in India, $303 billion in Russia and $33 billion in the UK.

Countries such as Brazil, China, Russia and India currently lose more than 20 million productive life-years annually to chronic disease, and that number is expected to grow 65% by 2030. The losses in productivity associated with those diseases like disability, unplanned absences and increased accidents are as much as 400% more than the cost of treatment.

Proven health benefits

Workplace health promotion has generally focused on promoting worker health through the reduction of individual risk-related behaviours such as tobacco use, physical inactivity and poor nutrition. These programmes have the potential to reach a significant proportion of employed adults, up to 54% of the world population.

In 2003, a comprehensive study² focusing on the economic return of workplace health promotion concluded that workplace programmes can achieve a 25-30% reduction in medical and absenteeism costs in an average period of about 3.6 years. It also showed:

• An average 27% reduction in sick leave absenteeism
• An average 26% reduction in healthcare costs
• An average 32% reduction in workers' compensation and disability claim costs
• An average US$ 5.81-US$ 1.00 savings-to-cost ratio


reference: http://www.world-heart-federation.org/what-we-do/world-heart-day/world-heart-day-2009/
for more details log on to: http://www.world-heart-federation.org

Early Results: In Children, 2009 H1N1 Influenza Vaccine Works Like Seasonal Flu Vaccine

Early Results: In Children, 2009 H1N1 Influenza Vaccine Works Like Seasonal Flu Vaccine

Early results from a trial testing a 2009 H1N1 influenza vaccine in children look promising, according to the trial sponsor, the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. Preliminary analysis of blood samples from a small group of trial participants shows that a single 15-microgram dose of a non-adjuvanted 2009 H1N1 influenza vaccine — the same dose that is in the seasonal flu vaccine — generates an immune response that is expected to be protective against 2009 H1N1 influenza virus in the majority of 10- to 17- year-olds eight to 10 days following vaccination. These results are similar to those recently reported in clinical trials of healthy adults. Younger children generally had a less robust early response to the vaccine.

"This is very encouraging news," says NIAID Director Anthony S. Fauci, M.D. "As we had hoped, responses to the 2009 H1N1 influenza vaccine are very similar to what we see with routinely used seasonal influenza vaccines made in the same way. It seems likely that the H1N1 flu vaccine will require just one 15-microgram dose for children 10 to 17 years of age. The 2009 H1N1 influenza virus is causing widespread infections among children, so these are welcome results."

The ongoing NIAID-sponsored trial began in mid-August at five sites nationwide. The trial is assessing the safety and immune responses to one and two doses of either 15 micrograms or 30 micrograms of vaccine. Data from the trial is being compared for three age groups: children 6 months to 35 months old; 3 to 9 years old; and 10 to 17 years old.

The preliminary results are based on blood samples taken eight to 10 days after the first vaccination. Immune responses were strongest among the oldest children, those 10 to 17 years old. In this group of 25 children, a strong immune response was seen in 76 percent who received one 15-microgram dose of vaccine. The immune responses in children nine years old and younger were not as strong. Among 25 volunteers aged 3 to 9 years old, a strong immune response was seen in 36 percent of those given 15 micrograms of vaccine. In the youngest group, 20 children between 6 months to 35 months old, a single 15-microgram dose of vaccine produced a strong immune response in 25 percent of recipients.

"These results are not unexpected and are both similar to what is seen with seasonal influenza vaccines and consistent with what we and our colleagues at the Food and Drug Administration anticipated," notes Dr. Fauci.

Study investigators are also collecting blood samples from the volunteers approximately three weeks after both the first and second injections. It is anticipated that the immune response to the 2009 H1N1 influenza vaccine will be similar to that of seasonal influenza vaccination and will continue to rise for several weeks following vaccination, says Dr. Fauci. The study is being closely monitored by the trial physicians and staff as well as by an independent safety monitoring committee.

The vaccine being tested in this trial is manufactured by Sanofi Pasteur in Swiftwater, Pa., in the same manner as its licensed seasonal vaccine, which is used every year in millions of children, and is the same formulation recently licensed by the FDA to protect against 2009 H1N1 influenza. Like inactivated seasonal influenza vaccines, the vaccine contains a purified part of a killed virus and cannot cause flu.

NIAID is conducting trials of 2009 H1N1 influenza vaccines through its longstanding vaccine clinical trials network, the Vaccine and Treatment Evaluation Units. Additional information about the NIAID-sponsored clinical trials in children is available in an Aug. 18 Bulletin: http://www3.niaid.nih.gov/news/newsreleases/2009/H1N1pedvax.htm and a Q&A: http://www3.niaid.nih.gov/news/QA/qaH1N1pedvax.htm. A detailed description of the trial protocol is at clinicaltrials.gov: http://clinicaltrials.gov/show/NCT00944073.

For more information on influenza, including pandemic influenza and avian influenza, visit www.flu.gov. Also, see NIAID’s Web portal at http://www3.niaid.nih.gov/topics/Flu/.

NIAID conducts and supports research — at NIH, throughout the United States, and worldwide — to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID Web site at http://www.niaid.nih.gov.

The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.


reference: http://www.nih.gov/news/health/sep2009/niaid-21.htm

H1N1 Clinicians Questions and Answers

September 21, 2009, 4:00 PM ET

Who is recommended to receive the 2009 H1N1 flu vaccine?
When vaccine is first available, the CDC Advisory Committee on Immunization Practices (ACIP) has recommended the 2009 H1N1 vaccine for the following 5 target groups (approximately 159 million persons nationally):

• Pregnant women
• Household and caregiver contacts of children younger than 6 months of age (e.g. parents, siblings, and daycare providers)
• Health care and emergency medical services personnel
• Persons from 6 months through 24 years of age
• Persons aged 25 through 64 years who have medical conditions associated with a higher risk of influenza complications

Once providers meet the demand for vaccine among persons in these initial target groups, vaccination is recommended for all persons 25 through 64 years of age. Current studies indicate that the risk for infection among persons age 65 or older is less than the risk for younger age groups. However, once vaccine demand among younger age groups has been met, programs and providers should offer vaccination to people 65 or older.

How should providers prioritize among the initial target groups recommended by ACIP?
The recommendations are broad and allow for flexibility to accommodate local variability in vaccine needs and demands. Providers should be aware of and follow any additional guidance provided by their state or local health departments. If no additional guidance is provided at the state or local level, providers should vaccinate among the initial target group populations on a first come, first served basis.

How likely is it that recommendations for target groups may change during the immunization period?
Although it is unlikely the ACIP recommendations will change, predicting the behavior of 2009 H1N1 influenza virus is difficult. CDC will continue to monitor the epidemiology of the evolving pandemic very closely. The Advisory Committee on Immunization Practices will be updated frequently on the status of the pandemic, including groups at highest risk of complications, and recommendations will be modified as necessary.

How will the 2009 H1N1 vaccine flow from manufacturers to providers?
The Federal Government will allocate vaccine to states based on population size. States are responsible for identifying providers who will participate in administration of 2009 H1N1 vaccine. Vaccine will be shipped to participating providers through a centralized distribution process. Through this process, placing of orders is facilitated by the state/local health department, and this information sent to CDC to be transferred to the distributor for processing. Because of limitations related to the number of sites to which the distributor can directly ship vaccine, some project areas (includes all states, territories, Chicago, DC, NYC, and LA county) may develop additional means of distributing vaccine to providers which will be communicated to providers on a local level.

How can providers obtain vaccine?
State/Local public heath departments will be responsible for directing the flow of vaccine to providers within every state. They will determine which providers will receive vaccine, and will allocate vaccine among providers as it becomes available to them. Public health departments are in the process of ascertaining which providers are interested in administering vaccine. For more information go to your state’s public health department website or to the CDC 2009 H1N1 website for information on how to become a 2009 H1N1 vaccine provider. Participating providers will sign a Provider Agreement assuring they intend to meet state requirements

Will vaccine be distributed equitably across providers?
Public health departments will strive to ensure equitable distribution, taking into account which target groups are seen by different types of providers as well as their internal resources for possible re-distribution of vaccine.

What supplies will be included with the 2009 H1N1 vaccine shipments?
The Federal Government will purchase vaccine and supplies (syringes, alcohol swabs, sharps containers, and vaccine record cards) and distribute these at no cost to healthcare providers who make agreements with state and local public health authorities to provide the 2009 H1N1 vaccine. Supplies will be shipped separately from vaccine and are expected to arrive before or on the same day as vaccine.

How can providers determine what percentage of their patients plan on getting the 2009 H1N1 vaccine in a physician’s office?
It is difficult to predict where individuals will go to receive the 2009 H1N1 vaccine. However, based on unpublished data from the Adult National Immunization Survey, during the 2006-2007 influenza season, among 19-49 year olds who were vaccinated, approximately 38% of persons at increased risk of complications from influenza reported receiving influenza vaccine in a physician’s office. Approximately 26% of persons with household contact with a high risk person and 25% of persons with no specific indications for influenza vaccine were vaccinated in a physician’s office.

What are some possible approaches a practice might take to administer the 2009 H1N1 vaccine?
Options include holding special clinics, integrating the 2009 H1N1 vaccination into usual care, providing walk-in immunizations, or coordinating with local public health clinics if unable to administer 2009 H1N1 vaccine themselves. In determining the best option, each practice should consider several factors, including availability of vaccine, practice resources and patient demand.

If my patients are vaccinated outside of my practice, how will that information be available for inclusion in the patient’s permanent medical record?
Recipients of the 2009 H1N1 vaccine will be provided with a hand-held card to serve as a record of vaccination and a source of information should a report to the Vaccine Adverse Event Reporting System (VAERS) be needed. Vaccine recipients will be encouraged to bring the hand-held card at their next visit to their primary care provider so that vaccination information can be transcribed into the patient’s permanent medical record.

What CDC information will be available for use in practices to help explain the need for both seasonal and 2009 H1N1 vaccine?
A variety of materials are available on the CDC 2009 H1N1 website at http://www.cdc.gov/h1n1flu/vaccination/. In addition, a 2009 H1N1-specific Vaccine Information Statement (VIS) will be available that will help explain the vaccine to recipients.

Can partients who are allergic to eggs receive the 2009 H1N1 flu vaccine?
Asking persons if they can eat eggs without adverse effects is a reasonable way to determine who might be at risk for allergic reactions from receiving influenza vaccines. Persons who have had symptoms such as hives or swelling of the lips or tongue, or who have experienced acute respiratory distress after eating eggs, should consult a physician for appropriate evaluation to help determine if influenza vaccine should be administered. Persons who have documented (IgE)-mediated hypersensitivity to eggs, including those who have had occupational asthma related to egg exposure or other allergic responses to egg protein, also might be at increased risk for allergic reactions to influenza vaccine, and consultation with a physician before vaccination should be considered. A regimen has been developed for administering influenza vaccine to asthmatic children with severe disease and egg hypersensitivity (J Pediatr 1985;106:931-3.).

Will private health insurance plans reimburse private providers for administration of 2009 H1N1 vaccine?
According to America’s Health Insurance Plans, a national association representing nearly 1,300 companies that provide health insurance to over 200 million Americans, “Every year health plans contribute to the seasonal flu vaccination campaign in several ways:
a) Health plans communicate directly with plan sponsors and members on the current ACIP recommendations and encourage immunization; they also provide information on where to get vaccinations, and who to contact with any questions.
b) Just as health plans have provided extensive coverage for the administration of seasonal flu vaccines in the past, public health planners can make the assumption that health plans will provide reimbursement for the administration of 2009 H1N1 vaccine to their members by private sector providers in both traditional settings e.g., doctor’s office, ambulatory clinics, health care facilities, and in non-traditional settings, where contracts with insurers have been established.”

Can seasonal influenza vaccine and 2009 H1N1 vaccine be given at the same visit?
Both seasonal and 2009 H1N1 vaccines are available as inactivated and live attenuated (LAIV) formulations. The simultaneous and sequential administration of seasonal and 2009 H1N1 inactivated vaccines is currently being studied. However, existing recommendations are that two inactivated vaccines can be administered at any time before, after, or at the same visit as each other (General Recommendations on Immunization, MMWR 2006;55[RR-15]). Existing recommendations also state that an inactivated and live vaccine may be administered at any time before, after or at the same visit as each other. Consequently, providers can administer seasonal and 2009 H1N1 inactivated vaccines, seasonal inactivated vaccine and 2009 H1N1 LAIV, or seasonal LAIV and inactivated 2009 H1N1 at the same visit, or at any time before or after each other. Live attenuated seasonal and live 2009 H1N1 vaccines should NOT be administered at the same visit until further studies are done. If a person is eligible and prefers the LAIV formulation of seasonal and 2009 H1N1 vaccine, these vaccines should be separated by a minimum of four weeks.

Can 2009 H1N1 vaccine be administered at the same visit as other vaccines?
Inactivated 2009 H1N1 vaccine can be administered at the same visit as any other vaccine, including pneumococcal polysaccharide vaccine. Live 2009 H1N1 vaccine can be administered at the same visit as any other live or inactivated vaccine EXCEPT seasonal live attenuated influenza vaccine.

Will the 2009 H1N1 vaccine be recommended for patients who had influenza-like illness since spring 2009?
All persons in a recommended vaccination target group who did not have 2009 H1N1 virus infection confirmed by real-time reverse transcription-polymerase chain reaction (RT-PCR ) should be vaccinated with the 2009 H1N1 vaccine. However, most people ill with an influenza-like illness (ILI) since this spring have not had testing with the RT-PCR test, which is the only test that can confirm infection specifically with the 2009 H1N1 virus. Tests such as rapid antigen detection assays, and diagnoses based on symptoms alone without RT-PCR testing, cannot specifically determine if a person has 2009 H1N1 influenza. Persons who were not tested, but who became ill after being exposed to a person with lab confirmed 2009 H1N1 influenza should not assume that they also had 2009 H1N1 since many pathogens can cause an ILI, and should get the vaccine if they are in a recommended vaccination target group.

Persons who think they had 2009 H1N1 infection diagnosed by RT-PCR should ask their doctor if they should be vaccinated. Someone who was infected with the 2009 H1N1 virus and who is not severely immune compromised will likely have some immunity to subsequent infection with 2009 H1N1 virus. However, vaccination of a person with some existing immunity to the 2009 H1N1 virus will not be harmful and persons who are uncertain about how they were diagnosed should get the 2009 H1N1 vaccine. Additionally, persons recommended for seasonal vaccine should get a seasonal vaccine because infection with the 2009 H1N1 virus does not provide protection

reference: http://www.cdc.gov/h1n1flu/vaccination/clinicians_qa.htm

Pandemic influenza vaccines: current status

Pandemic (H1N1) 2009 briefing note 11

Related link: Pandemic influenza vaccine manufacturing process and timeline 6 August 2009

24 SEPTEMBER 2009 | GENEVA -- Regulatory authorities have licensed pandemic vaccines in Australia, China, Hungary and the United States of America, soon to be followed by Japan and several countries in Europe. The length of the approval process depends on factors such as each country's regulatory pathway, the type of vaccine being licensed, and the stage of manufacturers' readiness to submit appropriate information to regulatory authorities.

Production capacity

In May 2009, WHO estimated that, in a best case scenario, worldwide production capacity for pandemic vaccines would be approximately 5 billion doses per year. Since then, better information on production yield and appropriate vaccine formulation has become available.

WHO currently estimates worldwide production capacity for pandemic vaccines at approximately 3 billion doses per year. While this figure is lower than previously projected, early data from clinical trials suggest that a single dose of vaccine will be sufficient to confer protective immunity in healthy adults and older children, effectively doubling the number of people who can be protected with current supplies.

These supplies will still be inadequate to cover a world population of 6.8 billion people in which virtually everyone is susceptible to infection by a new and readily contagious virus. Global manufacturing capacity for influenza vaccines is limited, inadequate and not readily augmented.

Pandemic vaccines have their greatest impact as a preventive strategy when administered before or near the peak incidence of cases in an outbreak. Both regulatory authorities and vaccine manufacturers have made extraordinary efforts to expedite the availability of vaccines.

Many affluent countries have previously contracted with manufacturers to obtain sufficient vaccine supplies to cover their entire populations. However, most low- and middle-income countries lack the financial resources to compete for an early share of limited supplies. Vaccine supplies in these countries will largely depend on donations from manufacturers and other countries.

Availability in developing countries

Last week, donations of pandemic vaccines for use in developing countries were announced by the United States of America, in concert with Australia, Brazil, France, Italy, New Zealand, Norway, Switzerland and the United Kingdom. Similar support from additional countries is anticipated and warmly welcomed.

WHO will be coordinating the distribution of these donated vaccines. Earlier this year, WHO conducted surveys with its regional and country offices to identify countries that will not have pandemic vaccines unless supplies are donated.

Teams with expertise in field operations, vaccines, and the logistics of their distribution are now working in the JW Lee Centre for Strategic Health Operations (the SHOC room). Initially, they will be distributing an estimated 300 million doses of vaccine to more than 90 countries.

Distribution of the first batches of donated vaccines is expected to begin in November. WHO continues to recommend that health workers be given high priority for early vaccination.

Vaccine safety

National regulatory authorities for medicines carefully examine the known and suspected risks and benefits of any vaccine prior to its licensing. Because the pandemic virus is new, both non-clinical and clinical trials are being conducted to gain essential information on immune response and safety. Outcomes of trials completed to date suggest that pandemic vaccines are as safe as seasonal influenza vaccines.

Side effects are expected to be similar to those observed with seasonal influenza vaccines. Common side effects include local reactions at the injection site (soreness, swelling, redness) and possibly some systemic reactions (fever, headache, muscle or joint aches). In almost all vaccine recipients, these symptoms are mild, self-limited and last 1-2 days.

However, even very large clinical trials will not be able to identify possible rare events that can occur when pandemic vaccines are administered to many millions of people.

WHO advises all countries administering pandemic vaccines to conduct intensive monitoring for safety and to report adverse events. Many countries already have systems for monitoring vaccine safety in place.

International sharing of data from such post-marketing surveillance will be vital in guiding risk-benefit assessments and determining whether changes in vaccination policies are needed. WHO has developed standardized protocols for data collection and reporting in real-time, and will communicate findings to the international community via its web site.

http://www.who.int/csr/disease/swineflu/notes/pandemic_influenza_vaccines_20090924/en/index.html

Women and Stroke
Stroke is largely preventable. Yet worldwide, 15 million people suffer strokes each year. Of these, five million die and five million are left permanently disabled, placing a burden on family and community. i Indeed stroke is now the second leading cause of death worldwide, after ischemic heart disease. Demographic projections to 2020 suggest that it will remain so, given the aging of many populations. ii In the coming decades a marked increase in the number of stroke events is expected worldwide, particularly in South American and Asian countries.iii In parallel, stroke will be among the five most important causes of disability in developed and developing countries.iv
Stroke in review A type of cardiovascular disease, stroke is a sudden loss of brain function caused by reduced blood flow to the brain (ischemic stroke) or the rupture of blood vessels in the brain (hemorrhagic stroke). Because neurons in the area die, a variety of effects can result, depending on where the brain was injured and the extent of the damage. A stroke can affect a person’s emotions, behaviour and personality, as well as their ability to move and coordinate movement, communicate, reason, understand, remember, and more. 1
Why focus on women? Stroke is an important public health issue for women and men alike. Traditionally, however, it has been seen as a man’s disease − a faulty and dangerous perception. The reality is that stroke accounts for a higher proportion of deaths among women than men (11 percent vs. 8.4 percent v ), despite comparable stroke rates. In developing countries, half of all deaths of women over 50 are due to heart disease and stroke. vi And in the United States, one in 2.5 women die of heart disease, stroke and other cardiovascular diseases compared with one in 30 who die of breast cancer. vii Despite this, only 13 percent of women in the United States believe heart disease and stroke are the greatest health threat to women; women’s knowledge of stroke warning signs remains low. viii
Beyond mortality statistics, studies have shown that women who survive a stroke are more likely than men to have a poor outcome. ix More stroke survivors over age 65 are women, x and because of women’s longer life expectancy, those who survive strokes are more likely to live alone than men. This means a woman’s hospital stay will generally be longer than a man’s. Women are also more likely to be transferred to a chronic care facility rather than go home or to rehabilitation, xi markedly affecting their independence and quality of life.
Stroke risk factors While women and men share many risk factors for stroke, women face additional gender-specific risk factors. For example, hormone replacement therapy and oral contraceptive use increase stroke risk. xii
Most risk factors can be modified, treated or controlled, but some cannot. The more risk factors a person has, the greater their chance of having a stroke.
Risk factors that can be modified xiii include:
Hypertension
Diabetes
Smoking, especially when combined with oral contraceptives
Heart disease
Atrial fibrillation
Obesity and overweight
Physical inactivity
Unhealthy diet
Stress
Excessive alcohol intake
High total cholesterol
High triglyceride levels
Carotid artery disease
Transient ischemic attacks
Risk factors that cannot be modified include: xiv
Advancing age
Gender
Ethnicity/race
Family history of early stroke
Previous stroke
Stroke prevention Knowledge of risk factors and how to minimize them is the first step in stroke prevention. Preventive measures that can have a significant impact include: xv
regular monitoring of blood pressure, cholesterol and glucose levels;
smoking prevention or cessation;
regular exercise;
eating a diet that includes polyunsaturated and monounsaturated fats and is rich in fruits, vegetables, fish or omega-3 fatty acids, whole grains and nuts;
maintaining a healthy weight; and
limiting alcohol intake.
Preventive treatment, where indicated, may include the use of anticoagulants (e.g. warfarin) or antiplatelet agents (e.g. aspirin); carotid endarterectomy to surgically remove blood vessel blockages; or balloon angioplasty or stents to remedy fatty buildup that is clogging a vessel. xvi
Warning signs and symptoms Just as important as learning how to prevent stroke is knowing how to recognize one, because when a stroke occurs time is of the essence. Immediate medical care is critical to minimize brain damage and disability. As an American Stroke Association slogan underlines: Learn to recognize a stroke. Because time lost is brain lost. If an individual experiences any of the following they may be having a stroke and need immediate emergency care:
Sudden numbness or weakness of the face, arm or leg, especially on one side of the body.
Sudden confusion, trouble speaking or understanding.
Sudden trouble seeing in one or both eyes.
Sudden trouble walking, dizziness, loss of balance or coordination.
Sudden severe headache with no known cause. xvii
Of interest is a 2003 study that documented, reportedly for the first time, a significant difference in the way women and men describe their symptoms while they’re having a stroke. Women were 62 percent more likely than men to say they were feeling sensations not on the list of “traditional” stroke symptoms. In particular, women were more likely to report pain and changes in consciousness or disorientation. They were also generally more likely than men to report non-neurological symptoms like shortness of breath and chest pain. Study researchers say the results may help explain findings from other research showing that women often don’t get stroke treatment as quickly as men . xviii
Acute treatment Yet, it is immediate treatment that leads to improved outcomes. Acute treatment for stroke varies depending on whether the stroke is ischemic or hemorrhagic. For ischemic stroke, interventional therapy with a “clot-busting” drug, where available, must be administered within three hours of the stroke’s onset to work best. For hemorrhagic stroke, treatment may include surgery to prevent rupture and bleeding of aneurysms or arteriovenous malformations. Alternatively, less-invasive endovascular procedures may be used. xix
Beyond acute treatment Stroke is different in everyone. Some people make a good recovery while for others the end of acute treatment is the beginning of a long road to a dramatically different life. In particular, individuals with disability face weeks, months, perhaps years of re-learning and rehabilitation. Feelings of depression and worthlessness are common. But small gains can bring great joy; these must be celebrated. Hope is important.
Families, too, must adjust to a different pace and a changed loved one. They wonder if and when life will ever get back to normal. It may not. Fatigue is common, especially in family members who are full- or part-time caregivers. Strong, resilient families gradually find a way to support each other while supporting their loved one. Family and caregiver self-help groups can be helpful for families finding it difficult to cope.
Implications for nurses While helping women and families affected by stroke, nurses can also work with women of all ages to help evaluate their risk of stroke and support them in healthy choices aimed at enhancing stroke prevention. Smoking prevention and cessation is one area where nurses can be particularly effective (see the ICN fact sheet Nurses for Tobacco-Free Life xx ).
Promoting healthy lifestyles in girls and young women should be a high priority. Although cardiovascular disease generally reveals itself in middle age or beyond, risk factors are in large part determined by behaviours learned in childhood and continued in adulthood, such as smoking, lack of exercise and poor diet. According to the World Health Organization, these risks are starting to appear earlier than they once did. xxi
Nurses are also well placed to educate women on the symptoms and warning signs of stroke; available treatments; helpful resources; and expectations for acute and longer term care. Families should be provided with information, included in care decisions and encouraged to seek respite opportunities where needed.
On a broader level, nurses can draw on their professional knowledge and expertise to lobby for and contribute to the development of policies that support health promotion and disease prevention initiatives. This includes initiatives focused on and supportive of nurses themselves. Finally, nurses can contribute to the collection of stroke-related data that can enhance decision-making.
Current initiatives Reliable stroke data helps justify why a government should invest in stroke prevention and treatment. With this in mind, the World Health Organization has developed an international stroke surveillance system, STEPS-stroke. The framework provides standardized definitions that will facilitate comparison of stroke occurrence within a country over time, and allow comparisons between populations in many countries. Of particular value, the system will evaluate preventive efforts and guide health planning. xxii
Facts and figures
Each year in the United States, roughly 700,000 Americans have a new or recurrent stroke, with nearly 40,000 more women than men dying of a stroke. xxiii
African-American women are 1.5 times more likely to have a stroke and 1.3 times more likely to die of a stroke than white women. xxiv
Stroke death rates for women are higher in Central and Eastern Europe than in Northern, Southern and Western Europe. For example, the death rate in women aged 35 to 74 living in the Russian Federation is 14 times higher than in Switzerland. xxv
Almost 60 percent of the 50,000 strokes in Canada each year affect women. xxvi
Resources The Atlas of Heart Disease and Stroke. Published in September 2004 by the World Health Organization, in conjunction with the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services. Downloadable at www.who.int/cardiovascular_diseases/resources/atlas/en.
World Heart Federation: www.worldheart.org.
American Heart Association: www.americanheart.org.
American Stroke Association: www.americanstroke.org.
Heart and Stroke Foundation of Canada: www.heartandstroke.ca
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TELENURSING

Telenursing
Advances in telecommunications technologies are revolutionising education and health services globally, including the provision of nursing services. Decreasing time and distance, these advances increase access to health and healthcare, especially to underserved populations and those living in rural and remote areas. They help to manage the demand for services, ensure more effective use of human and health resources and facilitate education and research activities.
What is Telenursing Telenursing refers to the use of telecommunications technology in nursing to enhance patient care. It involves the use of electromagnetic channels (e.g. wire, radio and optical) to transmit voice, data and video communications signals. It is also defined as distance communications, using electrical or optical transmissions, between humans and/or computers.1
Telenursing is not new. In some settings nurses have provided health information and nursing advice over the telephone for decades. It is, however, a quickly expanding service. Teledelivery of health promotion and disease prevention services, as well as nursing diagnosis, treatment and education are developing rapidly. While Western countries have seen the greatest expansion to date, developing countries are also benefiting from teledistance technologies. Special licensure and certification are not usually required but systems need to be in place to ensure the delivery of safe practice and quality of care. The physical separation from the patient may make it more difficult to establish a therapeutic relationship and require nurses to develop enhanced communication skills as well as technological competency.
Applications Telelnursing applications are available in the home, hospital, through telenursing centres and through mobile units. Telephone triage and home care are the fastest growing applications today.
In home care nurses use systems that allow home monitoring of physiologic parameters, such as blood pressure, blood glucose, respiratory peak flow, and weight measurement, via the Internet.
Through interactive video systems, patients contact on-call nurses any time and arrange for a video consultation to address any problems; for example, how to change a dressing, give an insulin injection or discuss increasing shortness of breath. 2 This is especially helpful for children and adults with chronic conditions and debilitating illnesses, particularly those with cardiopulmonary diseases.3
Telenursing helps patients and families to be active participants in care, particularly in the self-management of chronic illness. It also enables nurses to provide accurate and timely information and support online. Continuity of care is enhanced by encouraging frequent contacts between health care providers and individual patients and their families.

Telenursing and Home Care
In the United States, employment in home health care is expected to increase 36% or more over the next 7 years.4
In the United States almost 46% of the on-site nursing visits could reasonably be replaced by Telenursing. 5 ,6 , 7, 8
In the United Kingdom 15% of in-home patient care episodes reported the need for telecommunications technology.9
In the United States, substituting half or more of the traditional home visits with TeleHomecare visits, agency costs can be cut in half.10
Studies in Europe suggest that a large number of patients could benefit from in-home telecommunication services.11
Telenursing is cost effective in reducing the requirement for, or the length of, hospital stays; in increasing access to services to widely dispersed populations; and in expanding high-quality home care services. In Denmark, where nurses working in an outpatient clinic for people with back problems maintained regular telephone contact with patients, the number of hospital admissions and 'bed days' was reduced by half 12. In Iceland, with its widely dispersed population, a telephone based nursing intervention to support mothers with difficult infants reduced fatigue and distress 13. Innovative programmes use telenursing to allow women with pregnancy-induced hypertension to remain at home. 14

Cost-effectiveness

More timely information to patients and families reduces the use of expensive health care services (physician's office, emergency units, hospitals and nursing homes).
Limited resources can benefit a large population spread over a broad geographical region.
Telenursing can reduce the requirement for, or the length of, hospital stays.
Adults with chronic conditions who need frequent monitoring, assessment, and maintenance but do not meet home care criteria or have no money to pay for services can benefit from technology.
The result is a decrease in total health care costs and increased access to health care with more appropriate use of resources.
(Source: Britton, Keehner, Still & Walden 1999)
Clinical information can be shared with other professional colleagues including national and international experts. A nurse in Northern Ireland established a telenursing scheme for patients with leg ulcers resulting in improved quality of service for patients on both sides of the Irish border and the development of enhanced nursing roles. 15
The new technologies also increase access to nurse education, particularly continuing education. Examples include teaching off campus, video-conferencing, online learning and multi media distance education. Clinical skills can be learned and practiced through patient simulation modelling. 16
Telenursing provides opportunities for mature nurses to bring their years of experience back to the clinical arena without enduring the physical burden of 'floor' nursing in hospitals.
The use of technology has shaped the development of ICNP®, a long term project that will provide a structured terminology and a classification that can be used to describe and organise nursing data, which can in turn be integrated into multidisciplinary health information systems. 17
Issues
In providing care from a distance policy makers and practitioners need to ensure that there are appropriate systems in place for the regulation of practice and practitioners; policies and standards to ensure safe, professional and ethical practice; and security, privacy and confidentiality of information.
Telenursing activities need to be integrated appropriately into the overall policy and strategy for the development of nursing practice, the provision of nursing services, and the education and training of nurses.