The effect of mass media campaigns on oral health knowledge: A systematic review and meta-analysis.

OBJECTIVES: Knowledge and awareness gained from mass media can prepare people for lifestyle changes and impact their health and well-being. Considering the differences in the results of primary studies, we decided to conduct this study to evaluate the effect of mass media campaigns on oral health knowledge as a systematic meta-analysis and review. METHOD: The databases such as the Web of Sciences (ISI), Scopus, PubMed/Medline, and the Cochrane Library were searched systematically until February 2022. Data pooling was performed using a random effects model. The effect sizes were estimated as odds ratios (ORs) with their 95% confidence intervals (CIs). Additional analyses, including sensitivity, subgroup, and publication bias analyses, were also conducted. RESULTS: Our meta-analysis comprised a total number of seven articles. The pooled results indicated significant increases in oral health knowledge among included studies (OR = 1.64, 95% CI: 1.20-2.24, p < 0.001). In subgroup analyses, the effects of mass media campaigns on oral health knowledge remained significant for the studies with follow-up of less than 150 weeks (OR = 1.69, 95% CI: 1.49-1.91) and working-age populations (OR = 1.80, 95% CI: 1.40-2.32) compared to other categories. CONCLUSION: In general, this study showed that mass media campaigns may have positive effects on oral health knowledge, especially in the working-age population; it seems that for improving health knowledge among children, more initiatives are needed. Besides, the effects of these campaigns seem to be time-dependent and higher in shorter follow-up periods.

The incidence of hip fracture in Shiraz, Iran: a promising rate comparing to previous studies.

We evaluate the incidence of hip fracture in 50 years old or above in southwest of Iran. Age-adjusted incidence rates of hip fracture, standardized to the 2000 US white population, were 79.55 per 105 in total and 66.51 and 92.37 per 105 in male and female, respectively. INTRODUCTION: Osteoporosis-related hip fracture is associated with considerable morbidity, mortality, and costs in older people. The aim of this study was to evaluate the incidence rate of hip fracture in the capital of Fars Province, southern Iran. METHODS: This study was conducted in Shiraz, Iran, from September 1, 2011, to August 30, 2012. All 50-year-old or above patients with hip fracture diagnosis, lived in Shiraz at least 6 months prior to hospital admission, were included in this study. All statistical analyses were performed using SPSS, version 18.0, and Microsoft Excel 2007 software. RESULTS: The mean age of 608 patients was 75.95 ± 11.07 and 353 (58.3%) were female. Age-adjusted incidence rates of hip fracture, standardized to the 2000 US white population, were 79.55 per 105 in total and 66.51 and 92.37 per 105 in male and female, respectively. The adjusted incidence rate of neck of the femur fracture (30.62 per 105 versus 23.49 per 105, p = 0.61) and intertrochanteric fracture (40.48 per 105 versus 28.5 per 105, p = 0.74) were higher in females than males but the differences were not statistically significant. Under the age of 65 years, the incidence rate of hip fracture was significantly higher in men, but after 65 years, it was higher among women. CONCLUSION: The rate of osteoporotic hip fracture was relatively low in southern Iran. However, by aging population, this rate will increase and health policy makers should implement targeted osteoporosis screening and management programs.

Brucellosis as a neglected disease in a neglected population: a seroepidemiological study of migratory nomads in the Fars province of Iran.

This study assessed the seroprevalence of brucellosis and its risk factors in migratory nomads in the Fars province of Iran. Active brucellosis was defined as the combination of clinical symptoms, including fever, chills, night sweats, headache, low back pain, arthralgia, or myalgia, and positive laboratory testing, including either a serum agglutination test (SAT) ⩾1:80 with a 2-mercaptoethanol (2-ME) test ⩾1:40, or a SAT <1:80 combined with a positive Coombs Wright test (CWT) at a titre of at least threefold higher than SAT titre results. For the 536 participants, the female (316, 59%) to male (220, 41%) ratio was 1·4 and the participants' mean age was 32·4 ± 18·9 (range 1-96) years. Of all participants, 325 (60·6%) showed clinical symptoms; in symptomatic participants, the Rose Bengal plate test was positive in 33 (6·1%) cases, the SAT was positive in 18 (3·3%) cases, and the 2-ME test was positive in 30 (5·5%) cases. Positive SAT and 2-ME results were seen in 18 (3·3%) cases, but a negative SAT and a positive CWT were found in 36 (6·7%) cases. As a result, active brucellosis was detected in 54 cases, indicating a prevalence of 10% (95% confidence interval 8-12). In conclusion, we determined that brucellosis is a prevalent yet neglected disease in this nomadic population. Brucellosis control is not possible as long as these high-risk populations remain neglected.

Serological evidence of H9N2 avian influenza virus exposure among poultry workers from Fars province of Iran.

BACKGROUND: Since the 1990s, influenza A viruses of the H9N2 subtype have been causing infections in the poultry population around the globe. This influenza subtype is widely circulating in poultry and human cases of AI H9N2 have been sporadically reported in countries where this virus is endemic in domestic birds. The wide circulation of H9N2 viruses throughout Europe and Asia along with their ability to cause direct infection in mammals and humans, raises public health concerns. H9N2 AI was reported for the first time in Iran in 1998 and at present it is endemic in poultry. This study was carried out to evaluate the exposure to H9N2 AI viruses among poultry workers from the Fars province. METHODS: 100 poultry workers and 100 healthy individuals with no professional exposure to poultry took part in this study. Serum samples were tested for antibodies against two distinct H9N2 avian influenza viruses, which showed different phylogenetic clustering and important molecular differences, such as at the amino acid (aa) position 226 (Q/L) (H3 numbering), using haemagglutination inhibition (HI) and microneutralization (MN) assays. RESULTS: Results showed that 17 % of the poultry workers were positive for the A/chicken/Iran/10VIR/854-5/2008 virus in MN test and 12 % in HI test using the titer ≥40 as positive cut-off value. Only 2 % of the poultry workers were positive for the A/chicken/Iran/12VIR/9630/1998 virus. Seroprevalence of non exposed individuals for both H9N2 strains was below 3 % by both tests. Statistical analyses models showed that exposure to poultry significantly increases the risk of infection with H9N2 virus. CONCLUSIONS: The results have demonstrated that exposure to avian H9N2 viruses had occurred among poultry workers in the Fars province of Iran. Continuous surveillance programmes should be implemented to monitor the presence of avian influenza infections in humans and to evaluate their potential threat to poultry workers and public health.

Factors associated with self-rated health status in Southwestern Iran: a population-based study.

OBJECTIVE: This study aimed to reveal the relationship between self-rated health (SRH) and objective health status in the general population in the Southwest of Iran. STUDY DESIGN: A cross-sectional study. METHODS: Data were collected by face-to-face interview with 3554 residents, aged ≥18 years, who were selected by multistage sampling procedure. Collected data included sociodemographic, SRH status, and medical conditions; chronic diseases and mental symptoms. SRH was indicated by a single question in five scales of very good, good, fair, poor and very poor. An ordinal logistic regression analysis was used. Independent variables were organized into four blocks: block 1, age, gender, marital status, education level, employment status, size of household and monthly household income; block 2, chronic or long-term illness (coronary heart disease, hypertension and diabetes mellitus); block 3, psychological disorders (anxiety, impatience and sleep disorders); and block 4 (visual, skin, hearing and oral disorders). RESULTS: SRH status in most subjects reported to be positive, indicating 47.3% as very good, 30.8% good, 16.2% fair, 3.3% bad and 2.4% very bad. In studied subjects, poorer SRH was significantly related to older age (odds ratio [OR], 1.01), low-education level (OR, 1.09), single status (OR, 1.25), monthly household income (OR, 1.21), more chronic or long-term illness (OR, 1.61), greater psychological health disorders (OR, 1.69), more dermatologic disorders (OR, 1.30), and hearing problems (OR, 1.47). CONCLUSION: Results of this study revealed that subjects with worse SRH were older with low-education level, lower household monthly income, more chronic illness, greater psychological health disorders, and more visual, skin, hearing and oral disorders. So, SRH, as indicated globally, can be used as a population screening tool to identify subjects who are most in need of public health services.

Prevalence of metabolic syndrome in pre- and postmenopausal Iranian women.

BACKGROUND AND AIMS: The metabolic syndrome (MetS) is a constellation of risk factors increasing the risk of developing cardiovascular disease and diabetes. Little information is available on the association between MetS and menopausal status in Iranian women. Therefore, the purpose of the current study was to examine the prevalence and severity of MetS in pre- and postmenopausal women based on two commonly employed assessment criteria. METHODS: A total of 490 premenopausal and 434 postmenopausal women from the Shiraz Women's Health Cohort Study were included in the study. MetS was defined according to the criteria of the National Cholesterol Education Program-Adult Panel Treatment III (NCEP-ATPIII) and the International Diabetes Federation (IDF). Clinical, biochemical and anthropometric measures were collected from all study participants for determination of MetS. RESULTS: The majority of participants had at least two components of MetS. Postmenopausal women, compared to premenopausal women, had a higher prevalence of MetS. The prevalences of MetS were 60.2% and 59.4% based on the NCEP-ATPIII and IDF definitions, respectively. Waist circumference, waist-to-hip ratio, blood pressure, and levels of fasting plasma glucose, total cholesterol, low density lipoprotein cholesterol, and triglycerides were higher in postmenopausal women compared to premenopausal women. CONCLUSIONS: MetS is a major threat to women's health and an aging population, and longitudinal studies to determine the mechanism of postmenopausal MetS are required.

Epidemiological characteristics of fatal traffic accidents in Fars province, Iran: a community-based survey.

OBJECTIVES: To determine the epidemiological characteristics of fatal traffic accidents in Fars province, Iran. STUDY DESIGN: This cross-sectional study included 3642 traffic accident deaths in Fars province, Iran between November 2009 and November 2011. The data source was the Fars Forensic Medicine Registry, which covers the entire province. According to Iranian law, all deaths resulting from injuries or accidents must be investigated to determine the exact cause of death by autopsy. All such deaths are referred to forensic medicine centres in each city, and all data are sent to the main centre in Shiraz, the capital city of Fars province. RESULTS: Males accounted for 78.3% of the decedents (sex ratio of almost 3.6:1), and the mean ± standard deviation age of all decedents was 32.2 ± 20.3 years. Autopsy reports indicated that head trauma was the most common cause of death. Most collisions were vehicle-vehicle crashes (52.3%), with cars and motorcycles being the most prevalent modes of transport (39.6% and 24.6%, respectively). Fatal accidents were most common during the summer. Most fatal injuries (61.4%) occurred on outer-city roads and 27.4% occurred on inner-city roads. Significant associations were found between decedent's status (car driver, motorcycle driver or passenger, pedestrian or passenger) and interval between injury and death, light conditions at the scene of the accident, place of death, site of injury and cause of death. CONCLUSION: Although the clinical management of trauma patients has improved in Iran, coordination between trauma system organizations is required to decrease the burden of injuries.

A Systematic Review of Nutrition Recommendation Systems: With Focus on Technical Aspects.

BACKGROUND: Nutrition informatics has become a novel approach for registered dietitians to practice in this field and make a profit for health care. Recommendation systems considered as an effective technology into aid users to adjust their eating behavior and achieve the goal of healthier food and diet. The purpose of this study is to review nutrition recommendation systems (NRS) and their characteristics for the first time. MATERIAL AND METHODS: The systematic review was conducted using a comprehensive selection of scientific databases as reference sources, allowing access to diverse publications in the field. The process of articles selection was based on the PRISMA strategy. We identified keywords from our initial research, MeSH database and expert's opinion. Databases of PubMed, Web of Sciences, Scopus, Embase, and IEEE were searched. After evaluating, they obtained records from databases by two independent reviewers and inclusion and exclusion criteria were applied to each retrieved work to select those of interest. Finally, 25 studies were included. RESULTS: Hybrid recommender systems and knowledge-based recommender systems with 40% and 32%, respectively, were the mostly recommender types used in NRS. In NRS, rule-based and ontology techniques were used frequently. The frequented platform that applied in NRS was a mobile application with 28%. CONCLUSION: If NRS was properly designed, implemented and finally evaluated, it could be used as an effective tool to improve nutrition and promote a healthy lifestyle. This study can help to inform specialists in the nutrition informatics domain, which was necessary to design and develop NRS.

Promoter polymorphism of transforming growth factor-beta1 gene and ulcerative colitis.

AIM: To elucidate the possible difference in two promoter polymorphisms of the transforming growth factor-beta1 (TGF-beta1) gene (-800G > A, -509C > T) between ulcerative colitis (UC) patients and normal subjects. METHODS: A total of 155 patients with established ulcerative colitis and 139 normal subjects were selected as controls. Two single nucleotide polymorphisms within the promoter region of TGF-beta1 gene (-509C > T and -800G > A) were genotyped using PCR-RFLP. RESULTS: There was a statistically significant difference in genotype and allele frequency distributions between UC patients and controls for the -800G > A polymorphism of the TGF-beta1 gene (P < 0.05). The frequency of the TGF-beta1 gene polymorphism at position -800 showed that the AA genotype and the allele A frequencies significantly differed between the patients and healthy controls (P < 0.05). At position -509, there was no statically significant difference in genotype and allele frequency between the patients and control subjects. CONCLUSION: The results of our study indicate that there is a significant difference in both allele and genotype frequency at position -800G > A of TGF-beta1 gene promoter between Iranian patients with UC and normal subjects.

Anti-HBc & HBV-DNA detection in blood donors negative for hepatitis B virus surface antigen in reducing risk of transfusion associated HBV infection.

BACKGROUND & OBJECTIVE: Though sensitive screening assays for detection of hepatitis B virus surface antigen (HBsAg) are available, occasional cases of post-transfusion hepatitis B virus infection (PTH) still occur. The present study was undertaken to assess the prevalence of anti-hepatitis B core (anti-HBc) positivity and presence of HBV-DNA in serum sample of healthy blood donors negative for both HBsAg and anti-HCV antibody in Shiraz, Iran. Since anti-HBc detection is not mandatory in Iran, we evaluated whether anti-HBc detection could be adopted as a screening assay for safety of donated blood. METHODS: Two thousands serum samples negative for both HBsAg and anti-HCV collected from healthy blood donors were tested for the presence of anti HBc antibody. All samples positive for anti-HBc antibody were then investigated for determination of anti-HBc titre, anti-HBs titre, HbeAg and anti-HBe antibody by enzyme immunoassay (EIA). Every sample that tested negative for HBsAg but positive for anti-HBc alone or in combination with other serological markers was also examined for the presence of HBV-DNA by polymerase chain reaction (PCR). RESULTS: Of the 2000 samples tested, 131 (6.55%) blood samples were found to be positive for anti- HBc. HBV DNA was detected among 16 of 131(12.2%) anti-HBc positive specimens. Further, there was an association between the titration of anti-HBc antibody and the intensity of expected PCR product band. The liver function test results were all in normal range except in 4 of 16 HBV-DNA positive subjects. The mean levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in HBV-PCR positive subjects were 14 IU/l and 23.7 IU/l respectively. INTERPRETATION & CONCLUSION: Anti-HBc antibody should be tested routinely on blood donors volunteers and if the sample found positive regardless of anti-HBs titre, the blood should be discarded. Further testing for HBV-DNA would be appropriate to follow up the donor for HBV infection.

Prevalence of Non-alcoholic Fatty Liver Disease and Its Related Factors in Iran.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in developing and developed countries. Estimating the total prevalence of NAFLD by means of appropriate statistical methods can provide reliable evidence for health policy makers. OBJECTIVE: To determine the prevalence of NAFLD in Iran using a systematic review and meta-analysis. METHODS: We identified relevant studies by searching national and international databases. Standard error of the prevalence reported in each study was calculated assuming a binomial distribution. The heterogeneity between the results of the studies was determined using Cochran's Q and I square indices. We used a random effect model to combine the prevalence rates reported in the studies. RESULTS: We entered 23 eligible studies in this systematic review investigated NAFLD among 25,865 Iranian people. The total prevalence of NAFLD, prevalence of mild, moderate and severe fatty liver disease were estimated at 33.9% (95% CI 26.4%-41.5%), 26.7% (95% CI 21.7%-31.7%), 7.6% (95% CI 5.7%-9.4%), and 0.5% (95% CI 0.1%-0.9%), respectively. The majority of studies reported that NAFLD was more common among men (seven of eight studies), obese person (15 of 15 studies), older people (10 of 10 studies), patients with systolic hypertension (5 of 8 studies), patients with diastolic hypertension (7 of 9 studies), patients with hypertriglyceridemia (14 of 16 studies), patients with high HOMA level (4 of 4 studies), patients with metabolic syndrome (4 of 4 studies), and those with elevated serum ALT (8 of 12 studies). CONCLUSION: Our study showed that the prevalence of NAFLD in Iran was relatively high and male gender, old age, diabetes, metabolic syndrome, systolic/diastolic hypertension, high serum ALT, and hypertriglyceridemia may be determinants of NAFLD.

Neurological complications of first 100 orthotopic liver transplantation patients in southern Iran.

Neurological complications which are responsible for significant mortality and morbidity after orthotopic liver transplantation have been reported in 8.3% to 47% of cases in various series. This prospective study was performed to investigate the prevalence and characteristics of neurological complications in the first 100 patients who have undergone orthotopic liver transplantation from 1993 to 2004. Neurological symptoms and signs as well as routine laboratory tests, including complete blood cell counts, electrolyte levels, drug levels, microbiologic and serological studies, brain computed tomography scans, magnetic resonance imaging, and electrodiagnostic studies were reviewed in all patients. Follow-up periods were from 2 months to 10 years. Nineteen patients of mean age of 34.9 years developed neurological complications after orthotopic liver transplantation. The most common neurological symptoms and signs were confusion (42.1% of cases with neurological complications), convulsions (36.8%), and hallucinations (31.6%). Hepatic encephalopathy (31.6%) and drug toxicity (26.2%) were the most common neurological syndromes. The mortality rate was significantly higher among patients with neurological complications. Compared to other centers, neurological complications were less common in our center.

Serum leptin level in patients with functional dyspepsia.

UNLABELLED: BACKGROUND/GOAL: Previous studies have shown that leptin plays a major role in the amount of food consumption. Recently, leptin and its receptors have been found in the human gastric mucosa. The aim of this study was to seek any possible correlation between serum leptin level and subtypes and pathological findings in functional dyspepsia. MATERIALS AND METHODS: In a prospective study, we randomly select 44 patients as dysmotility-like and ulcer-like dyspepsia (according to ROME II criteria) in two equivalent groups and compared them with 22 healthy volunteers control group who matched the patients in relation to age, sex and body mass index. From each patient, a fasting blood sample for leptin level and two antral biopsies for evaluating the intensity of gastritis and Helicobacter pylori infection were provided and compared with the control group. RESULTS: Compared to the control group, serum leptin level was significantly higher in patients with dysmotility-like dyspepsia (P < 0.05). Leptin level were also significantly correlated with the presence of gastritis and H. pylori infection (P < 0.05). CONCLUSION: Leptin may have a role in the pathogenesis of the dysmotility variety of non-ulcer dyspepsia through mechanisms other than H. pylori infection. Further studies based on gastric leptin immunohistochemistry may need correlation between symptoms of functional dyspepsia and gastric leptin expression.

Comparison of intradermal and intramuscular administration of hepatitis B vaccine in neonates.

BACKGROUND: Hepatitis B virus (HBV) infection and its complications are among the most common diseases in Iran. National mass vaccination of neonates against hepatitis B was started in 1991, but was considered a costly venture. AIM: To compare the efficacy of low-dose intradermal HBV recombinant vaccine with standard intramuscular dose in neonates. METHOD: 165 apparently healthy neonates born in Shiraz were randomized to receive either 10 microg [corrected] of recombinant vaccine intramuscularly (IM; n=82) or 2 microg [corrected] vaccine intradermally (ID; n=83) at months 0, 1, 6. Anti-HBs titers were measured at 6 and 18 months after the first dose. RESULTS: 53 and 51 neonates in the IM and ID groups, respectively, completed the study. Protective anti-HBs titers (>10 IU/L) at 18 months after the first dose were achieved in 98.1% and 96.2% of neonates in IM and ID groups, respectively (p=ns). The only side effect in the ID group was local hyperpigmentation, which was seen in 55%; no significant side effect was reported in the IM group. CONCLUSION: Intradermal vaccination with 20% of standard dose is as effective as IM vaccination when evaluated at 18 months after the first dose.

Hyperhomocysteinaemia, hyperlipidaemia and risk of venous thromboembolism in Shiraz.

To assess the risk of venous thromboembolism (VTE) associated with hyperhomocysteinaemia (hyper-Hcy) and hyperlipidaemia, we performed a case-control study. Fasting total homocysteine (Hcy), triglyceride and cholesterol levels were assessed in 43 patients with VTE and 43 controls. Mean Hcy level was significantly higher in the test group. Odds ratio (OR) for VTE in patients with hyper-Hcy was 2.7, with the association stronger in women and those under 50. The OR for those with both hypertriglyceridaemia and hypercholesterolaemia was significantly greater in those under 50. Increased risk for venous thrombosis was found among those under 50 having both lipid abnormalities.

Pulmonary tuberculosis in migratory nomadic populations: the missing link in Iran's National Tuberculosis Programme.

OBJECTIVE: To detect pulmonary tuberculosis (PTB) in migratory nomadic populations in Fars Province, southern Iran. DESIGN: Cross-sectional study. RESULTS: In this study, 5506 (82.8%) of a total nomad population of 6650 from 1337 tents were screened for PTB. The mean age was 27.4 ± 18.2 years (range 1-109). Based on clinical symptoms, 141/5506 (2.6%) were identified as TB suspects. One male and three female adult new smear-positive PTB cases were detected, giving an incidence rate of 0.7/1000 population compared to 0.08/1000 in the general population of the region, and 28.4/1000 TB suspects. The median time to onset of symptoms in detected cases was 82.5 days. Tribal stigma against female TB patients was one of the main barriers to appropriate health-seeking behaviour. CONCLUSIONS: The incidence of smear-positive PTB among migratory nomads is approximately nine-fold higher than in the general population. Active screening of TB in migratory nomads should be integrated into Iran's national TB control programme. The issue of destigmatisation, particularly among female TB patients, should also be addressed.

Prevalence of breast cancer in a defined population of iran.

BACKGROUND: Prevalence of breast cancer in Asian developing countries is much lower than western developed countries. The main aim of this study was to measure breast cancer prevalence in a defined population of Iran. METHODS: A total of 25201 women who were under coverage of "Imam Khomeini Relief Foundation (IKRF)", which is an organization for delivering supportive social and cultural services to the deprived and poor subgroups of the society, were involved in the study. The study was conducted during years 2007 and 2008. All subjects were interviewed for their socio-demographic features and underwent precise clinical and para-clinical breast examination. RESULTS: Mean age was 47 years with standard deviation 10 ranging from 11 to 88 years. Subjects were from deprived subgroups of the community; were mainly illiterate or had primary school education (86%) and majority of them (93%) had their first full-term pregnancy at age less than 26 years and also were multiparous. With confirmed diagnosis by breast biopsy, breast cancer prevalence was 0.15% (95%CI; 0.10-0.20). CONCLUSION: Compared with developed countries, Asian developing countries have been at a lower risk of breast cancer development. It is seen that more deprived subgroups are at much lower risk. The more industrialized life is accompanied with more hazards.

Mortality from Pandemic Influenza A (H1N1) in Iran.

BACKGROUND: Due to worldwide spread of influenza A (H1N1) virus, the World Health Organization declared the first pandemic of influenza in four decades. This study aims to report the mortality from pandemic influenza A (H1N1) in Iran population and its epidemiologic and clinical characteristics up to December 21, 2009. METHODS: The data were obtained from all provinces and reported to center for disease control of Ministry of Health and Medical Education (MOHME) of Iran through nationwide surveillance system for influenza A (H1N1) was implemented by MOHME since April 2009. RESULTS: Of 3672 confirmed cases of influenza A (H1N1) in Iran between 22 May and 21 December 2009, 140 (3.8%) deaths were reported, mostly in 15-65 year old (yo) age group (67%). The highest admission mortality rate was in > 65 yo group (107 deaths/1000 hospitalized cases). Of decedent patients, 54% had no long term condition or risk factor, 34% had one, 11% had two, and 1% had three. Diabetes mellitus, pregnancy, chronic respiratory diseases and hypertension were the most common underlying conditions. The most common clinical pictures of death were acute respiratory distress syndrome and viral pneumonia. Although 66% of decedent patients received oseltamivir, enough information was not available about time of onset of antiviral therapy. CONCLUSION: As death due to influenza A (H1N1) occurs in all age groups and in those with and without any predisposing factors, we recommend health policy makers to provide influenza vaccination for people with underlying conditions and respiratory hygiene for all people.