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Biomedical subjects

S C Redd

Publications and source records attributed to S C Redd.

At least 37 records · Page 2Linked to original sources
PubMed1997

Palpation as a method of fever determination in Malawian children who are less than 5 years old: how reliable is it?

Fever is a common occurrence in children who are < 5 years old and palpation of the forehead may or may not be a reliable method for determining fever in such children. In a study of 1120 Malawian children of this age attending outpatient's clinics, each child's mother and a clinical officer (CO) were asked to palpate the child's forehead and decide whether the child was febrile (felt warm or very warm) or afebrile (felt normal). The rectal temperature of each child was then taken using a thermometer and the child considered febrile if this temperature was > or = 38 degrees C. Using palpation, mothers judged 973 (86.9%) of 1120 children to be febrile and CO judged 565 (50.4%) of 1118 to be febrile, whereas thermometer readings indicated 410 (36.7%) to be truly febrile. False-positives (i.e. afebrile children judged to be febrile by palpation) accounted for 574 (59.0%) of the 973 children who were considered febrile by their mothers and 228 (40.4%) of the 565 children so considered by CO; mothers reported significantly more false-positives than CO (P < 0.05). False-negatives (i.e. febrile children judged to be afebrile by palpation) accounted for 11 (7.5%) of the 147 children who were considered afebrile by their mothers and 73 (13.2%) of the 553 children so considered by CO; CO reported significantly more false-negatives than mothers (P < 0.05). Overall, mothers were as likely as CO to misjudge a child (721/1120 v. 781/1118; P > 0.05). Although the sensitivity of mothers and CO in determining fever was similar (97.3% v. 82.2%; P > 0.05), CO gave a higher degree of specificity than the mothers (67.8% v. 19.2%; P < 0.000001). Although the present results indicate that palpation is not a reliable method of determining fever in children who are < 5 years old, caregivers should continue to use palpation as a useful first step in deciding when a child needs to be referred.

Body Temperature↗
PubMed1997

Evaluation of an algorithm for integrated management of childhood illness in an area of Kenya with high malaria transmission.

In 1993, the World Health Organization completed the development of a draft algorithm for the integrated management of childhood illness (IMCI), which deals with acute respiratory infections, diarrhoea, malaria, measles, ear infections, malnutrition, and immunization status. The present study compares the performance of a minimally trained health worker to make a correct diagnosis using the draft IMCI algorithm with that of a fully trained paediatrician who had laboratory and radiological support. During the 14-month study period, 1795 children aged between 2 months and 5 years were enrolled from the outpatient paediatric clinic of Siaya District Hospital in western Kenya; 48% were female and the median age was 13 months. Fever, cough and diarrhoea were the most common chief complaints presented by 907 (51%), 395 (22%), and 199 (11%) of the children, respectively; 86% of the chief complaints were directly addressed by the IMCI algorithm. A total of 1210 children (67%) had Plasmodium falciparum infection and 1432 (80%) met the WHO definition for anaemia (haemoglobin < 11 g/dl). The sensitivities and specificities for classification of illness by the health worker using the IMCI algorithm compared to diagnosis by the physician were: pneumonia (97% sensitivity, 49% specificity); dehydration in children with diarrhoea (51%, 98%); malaria (100%, 0%); ear problem (98%, 2%); nutritional status (96%, 66%); and need for referral (42%, 94%). Detection of fever by laying a hand on the forehead was both sensitive and specific (91%, 77%). There was substantial clinical overlap between pneumonia and malaria (n = 895), and between malaria and malnutrition (n = 811). Based on the initial analysis of these data, some changes were made in the IMCI algorithm. This study provides important technical validation of the IMCI algorithm, but the performance of health workers should be monitored during the early part of their IMCI training.

Algorithms↗
PubMed1996

Antibody response to measles-mumps-rubella vaccine of children with mild illness at the time of vaccination.

OBJECTIVE: To examine the response to measles-mumps-rubella (MMR) vaccine among children with and without mild illness. DESIGN: Prospective cohort. PARTICIPANTS: A total of 386 children aged 15 to 23 months. MAIN OUTCOME MEASURES: Seroconversion rates to measles, mumps, and rubella in ill and well children. SETTING: Six public health immunization clinics in two counties in the greater metropolitan Atlanta, Ga, area from February 1992 to April 1993. RESULTS: Acute upper respiratory tract infection, otitis media, and diarrhea were observed in 128 (33%), 41 (11%), and 13 (3%) of the children (groups are not mutually exclusive); 157 children had one of these mild illnesses and 229 were well. Overall seroconversion rates were 98% for measles, 83% for mumps, and 98% for rubella antigens. Measles seroconversion rates for ill children compared with well children, respectively, were as follows: upper respiratory tract infection, 99% vs 97%; mild fever, 98% vs 97%; otitis media, 98% vs 98%; diarrhea, 100% vs 98%; and any mild illness, 99% vs 97%. Estimates of the magnitude of antibody response to measles, mumps, and rubella antigens were the same for children with and without mild illness. There was no association of mild illness with increased rates and severity of adverse events reported in the 2 weeks after vaccination. CONCLUSIONS: Vaccinating children who present with mild illnesses with MMR vaccine is a safe and efficacious practice. These results support recommendations of the Advisory Committee on Immunization Practices and the American Academy of Pediatrics.

Antibodies, Viral↗
PubMed1996

Clinical algorithm for treatment of Plasmodium falciparum malaria in children.

BACKGROUND: Identification of children who need antimalarial treatment is difficult in settings where confirmatory laboratory testing is not available, as in much of sub-Saharan Africa. The current national policy in Malawi is to treat all children with fever, usually defined as the mother's report of fever in the child, for presumed malaria. To assess this policy and to find out whether a better clinical case definition could be devised, we studied acutely ill children presenting to two hospital outpatient departments in Malawi. METHODS: The parent or guardian of each enrolled child (n = 1124) was asked a standard series of questions about the symptoms and duration of the child's illness. Each child was examined, axillary and rectal temperatures and blood haemoglobin concentrations were measured, and a giemsastained thick smear was examined for malaria parasites. Logistic regression procedures were used to identify clinical predictors of parasitaemia. FINDINGS: High temperature (37.7 degrees C or above), nailbed pallor, enlarged spleen, and being seen at one of the clinics rather than the other were associated with an increased risk of malaria parasitaemia in univariate analyses. A revised malaria case definition of rectal temperature of 37.7 degrees C or higher, splenomegaly, or nailbed pallor was 85% sensitive in identifying parasitaemic children and 41% specific; the corresponding sensitivity and specificity for the nationally recommended definition that equates mother's history of fever with malaria were 93% and 21%. The revised case definition had 89% sensitivity in identifying parasitaemic children with haemoglobin concentration below 80 g/L and 89% sensitivity in identifying children with parasite density greater than 10,000/microL, characteristics that indicate a clear need for antimalarial treatment. INTERPRETATION: These results suggest that better clinical definitions are feasible, that splenomegaly and pallor are helpful in identifying children with malaria, and that much overtreatment of children without parasitaemia could be avoided.

Algorithms↗
PubMed1996

The effect of oral iron therapy during treatment for Plasmodium falciparum malaria with sulphadoxine-pyrimethamine on Malawian children under 5 years of age.

In sub-Saharan countries, although malaria and malaria-associated anaemia are major public health problems, the usefulness of supplementary iron treatment for children with malaria-associated anaemia is unknown. In a 6-week period during the 1995 rainy season, 222 Malawian children aged < 5 years, who sought treatment for malaria, had > or = 500 parasites/microliter blood and at least 5 g haemoglobin (HB)/dl blood and whose parents gave consent, were randomized into a prospective study comparing the efficacy of sulphadoxine- pyrimethamine only (SP), SP plus daily iron (SPD) and SP plus weekly iron (SPW) as treatment for malaria-associated anaemia. The patients had their HB concentrations measured on enrollment (day 0), just before antimalarial treatment, and on days 3, 7, 14, 21 and 28; 215 (96.8%) completed the 28-day study. Among the children with 5-8 g HB/dl on enrolment, HB gain by the end of the study was significantly greater than in the children with > 8 g HB/dl initially (4.1 v. 2.2 g/dl; P < 0.05), and those in the SPD group gained significantly more HB by days 21 and 28 (3.6 and 4.9 g/dl, respectively) than those in either the SPW (2.7 and 3.7 g/dl, respectively) or the S2 groups (2.6 and 3.5 g/dl, respectively); there was no difference in HB gain between the SP and SPW groups. Type of treatment had no apparent effect, at any time during the study, on HB gains in those patients who had > 8 g HB/dl on enrolment. Thus the children with 5-8 g HB/dl on enrolment benefited from daily iron therapy whereas those with > 8 g HB/dl derived no significant benefit; improvement in HB depended most on whether enrolment HB was < or = 8.0 g/dl. As treatment with an effective antimalarial drug resulted in HB gains, irrespective of treatment group or HB concentration at enrolment, the anaemia observed may be mostly related to malaria. However, as a larger proportion of the iron-treated patients failed to clear their parasitaemias than of those given SP alone, oral iron may inhibit SP action. It is therefore recommended that, for children with both malaria and malaria-associated anaemia, the malaria should first be cleared with an effective antimalarial drug, such as SP, before the anaemia, if it still persists, is treated with iron.

Antimalarials↗
PubMed1996

Efficacy of sulphadoxine/pyrimethamine for Plasmodium falciparum malaria in Malawian children under five years of age.

In March 1993, sulphadoxine/pyrimethamine (SP) replaced chloroquine as the first line drug for malaria treatment in Malawi. Since then, the Ministry of Health has been receiving anecdotal and written reports of SP treatment failures in children. To determine whether treatment failure with SP was a widespread problem, children < 5 years of age with axillary temperature > 38.0 degrees C and parasite density > 2000/mm3 attending the outpatient clinics of the Mangochi and Karonga District Hospitals were enrolled in the study with parental consent. These were then followed for 28 days or until they failed clinically. Of 159 patients enrolled, 145 (91.2%) were followed for 28 days or until clinical failure. Of these, none had RII resistance and 3 (1.9%) had RIII resistance: 2/69 (2.9%) in Mangochi and 1/76 (1.3%) in Karonga; 142/145 (97.9%) exhibited RI/sensitive patterns. Of those followed to day 28 or to clinical failure, 77.1% had parasite clearance by day 3 and 98.6% had parasite clearance by day 7. Of those with temperature readings (n = 140), 129 (92.1%) clinically improved on day 3 and 98.6% improved by day 7. Other indicators of clinical improvement (from day 0 to day 3) included, reported increased level of activity in 136 (97.1%) of the children, and mother's impression of child's improvement in 113 (80.7%). Of the 14 patients not followed to day 28 or to clinical failure, 11 were lost to follow-up by day 7. No allergic skin reactions were noted, and no deaths were observed. These data show that after one year of widespread use of SP in Malawi, Plasmodium falciparum parasite resistance remains very low, and therefore contradicts reports of widespread parasite resistance to SP.

Age Factors↗
PubMed1996

Cardiac effects of standard-dose halofantrine therapy.

The antimalarial drug halofantrine hydrochloride has been associated with cardiac arrhythmias. This is a report of a study on the cardiac effects of standard-dose halofantrine (24 mg/kg) on a sample of 48 patients selected from a group of 402 Dega (Montagnard) refugees treated for Plasmodium falciparum infection. Prolongation of the rate-corrected QT interval (QTc) on the electrocardiogram (ECG) was used as an indicator of risk for halofantrine-associated cardiac arrhythmias. We found that standard-dose halofantrine was associated with a lengthening of the mean QTc from 0.04 sec(1/2) to 0.44 sec(1/2). Two patients had a QTc increase of greater than 25%, but none had a follow-up QTc of more than 0.55 sec(1/2), an interval length generally considered to be a risk factor for ventricular arrhythmias. Regression analysis indicated that pretreatment ECGs were poorly predictive of QTc lengthening during therapy, although pretreatment ECGs may be useful to evaluate patients with pre-existing cardiac conditions. The manufacturer has recommended that the halofantrine dose not exceed 24 mg/kg and revised the list of medication contraindications to include some cardiac conditions. Clinicians should weigh a patient's risk, including history of cardiac disease and availability of alternative therapy before use of halofantrine.

Adolescent↗
PubMed1996

Transplacental transmission of Plasmodium falciparum in rural Malawi.

Malaria during pregnancy may result in fetal exposure to malaria when parasites are transmitted across the placenta. To document the rate of transplacental passage of Plasmodium falciparum and to identify the risk factors for congenitally acquired malaria infection, we examined umbilical cord blood for malaria parasites from 2,080 newborn infants born to mothers enrolled in a study of malaria prophylaxis during pregnancy. Cord blood parasitemia was detected in 140 (6.7%) newborn infants with a geometric mean density of 187 parasites/microliter (range 12-99, 752 parasites/microliter). The likelihood of umbilical cord blood parasitemia was closely linked to the parasite density of placental malaria infection and the density of maternal peripheral blood parasitemia at the time of delivery; all babies born to women with both placental and peripheral blood parasitemia densities > or = 10,000/microliter had cord blood parasitemia. In a multivariate logistic regression model, male sex, premature delivery, and placental and maternal peripheral blood malaria parasitemia were independently associated with a baby being born with umbilical cord blood parasitemia. In this setting, highly endemic for malaria, transplacental transmission of malaria from infected placentae occurs frequently and is directly related to the density of maternal malaria infection.

Adolescent↗
PubMed1996

An evaluation of clinical indicators for severe paediatric illness.

To help reduce paediatric morbidity and mortality in the developing world, WHO has developed a diagnostic and treatment algorithm that targets the principal causes of death in children, which include acute respiratory infection, malaria, measles, diarrhoeal disease, and malnutrition. With this algorithm, known as the Sick Child Charts, severely ill children are rapidly identified, through the presence of any one of 13 signs indicative of severe illness, and referred for more intensive health care. These signs are the inability to drink, abnormal mental status (abnormally sleepy), convulsions, wasting, oedema, chest wall retraction, stridor, abnormal skin turgor, repeated vomiting, stiff neck, tender swelling behind the ear, pallor of the conjunctiva, and corneal ulceration. The usefulness of these signs, both in current clinical practice and within the optimized context of the Sick Child Chart algorithm in a rural district of western Kenya, was evaluated. We found that 27% of children seen in outpatient clinics had one or more of these signs and that pallor and chest wall retraction were the signs most likely to be associated with hospital admission (odds ratio (OR) = 8.6 and 5.3, respectively). Presentation with any of these signs led to a 3.2 times increased likelihood of admission, although 54% of hospitalized children had no such signs and 21% of children sent home from the outpatient clinic had at least one sign. Among inpatients, 58% of all children and 89% of children who died had been admitted with a sign. Abnormal mental status was the sign most highly associated with death (OR = 59.6), followed by poor skin turgor (OR = 5.6), pallor (OR = 4.3), repeated vomiting (OR = 3.6), chest wall retraction (OR = 2.7), and oedema (OR = 2.4). Overall, the mortality risk associated with having at least one sign was 6.5 times higher than that for children without any sign. While these signs are useful in identifying a subset of children at high risk of death, their validation in other settings is needed. The training and supervision of health workers to identify severely ill children should continue to be given high priority because of the benefits, such as reduction of childhood mortality.

Cause of Death↗
PubMed1995

Using clinical signs to diagnose anaemia in African children.

Anaemia is a serious and common problem among young children in sub-Saharan Africa. As a first step towards developing guidelines for its recognition and treatment, we conducted a study to evaluate the ability of health workers to use clinical findings to identify children with anaemia. Health care workers examined a total of 1104 children under 5 years of age at two hospital-based outpatient clinics in rural Malawi. Blood samples were taken to determine haemoglobin concentrations. Pallor of the conjunctiva, tongue, palm or nail beds was 66% sensitive and 68% specific in distinguishing children with moderate a anaemia (haemoglobin concentration, 5-8 g/dl) and 93% sensitive and 57% specific in distinguishing those with severe anaemia (haemoglobin concentration, < 5 g/dl). Even without laboratory support, which is often unavailable in rural Africa, clinical findings can identify the majority of children with anaemia.

Anemia↗
PubMed1995

Severe illness in African children with diarrhoea: implications for case management strategies.

To identify clinical disorders associated with severe illness in African children with diarrhoea, we studied a group of under-5-year-olds with diarrhoea who had been brought to a large public hospital in central Cote d'Ivoire. The general condition of children with diarrhoea was assessed and classified according to criteria recommended by WHO, and then used as a nonspecific indicator of severity. Of the 264 children with diarrhoea who were enrolled in the study, 196 had nonsevere illness and 68 severe illness. Children with severe illness were significantly more likely than those with nonsevere illness to be dehydrated (45% versus 11%), moderate-to-severely wasted (47% versus 29%), bacteraemic (26% versus 9%), severely anaemic (haemoglobin level <6 g/dl; 15% versus 6%), have Plasmodium falciparum parasitaemia (27% versus 14%), and have two or more of these five conditions (60% versus 14%). Nontyphoidal Salmonella spp. were present in 68% of the blood isolates but were not associated with seropositivity to human immunodeficiency virus (HIV). The study demonstrates the need for a more comprehensive approach to assessment and management of children with diarrhoea that ensures prompt recognition of bacteraemia, anaemia, wasting and malaria, as well as dehydration. Simple nonspecific observational criteria, such as those recommended by WHO for assessing and classifying general condition, are useful for identifying children with diarrhoea who are at high risk of having life-threatening clinical disorders, and can readily be used by health workers whose clinical training and access to diagnostic laboratory facilities are both limited.

Case Management↗
PubMed1994

Clinical signs of pneumonia in children attending a hospital outpatient department in Lesotho.

To determine the value of clinical findings for the diagnosis of pneumonia, we evaluated 950 children who presented with respiratory illness to the outpatient department of the Queen Elizabeth II Hospital, Maseru, Lesotho. Those children at high risk for pneumonia and a systematically selected 20% sample of children at low risk were examined in turn by a nurse, a general practitioner, and a paediatrician; a chest radiograph was recorded for each child. Pneumonia was defined as radiographic findings compatible with the disease as interpreted by a paediatric radiologist. A respiratory rate > or = 50 breaths/minute was a sensitive sign for pneumonia among infants (sensitivity range for the three examiners: 59-79%), but identified a progressively smaller proportion of children with pneumonia in older age groups. Adjusting the respiratory rate for age using a threshold of > or = 40 breaths/minute for children aged > or = 12 months improved the sensitivity, but identified < 30% of children with pneumonia aged > or = 24 months. No drop in sensitivity with age was found when respiratory rate thresholds were evaluated for children with more severe radiographic evidence of pneumonia.

Age Factors↗
PubMed1992

Usefulness of clinical case-definitions in guiding therapy for African children with malaria or pneumonia.

The World Health Organisation has developed disease-specific clinical case-definitions to guide management of children with fever or cough, the cardinal signs of malaria and pneumonia. To assess the usefulness of the case-definitions and to investigate their interaction, we studied children with fever or cough brought to a hospital in Lilongwe, Malawi. For all children, a thick blood smear was examined for Plasmodium falciparum parasites. Chest radiography was done only for children with parasitaemia and those who satisfied the clinical case-definition for pneumonia; others were assumed to have normal chest radiographs. Of 1599 enrolled children, 566 (35%) had parasitaemia and 116 had radiographic evidence of pneumonia; 43 had both pneumonia and parasitaemia. Of the 471 children who met the clinical definition for pneumonia, 449 (95%) also met the malaria clinical definition. Among children with radiographic evidence of pneumonia, the clinical definition for malaria was not predictive of parasitaemia (sensitivity 93%, specificity 5%). Whether malaria parasitaemia was present or absent, the pneumonia clinical definition distinguished children with and without radiographic evidence of pneumonia (sensitivity and specificity > 60%). Children who satisfied the pneumonia clinical definition were more likely to have radiographic evidence of pneumonia (odds ratio 10.4, 95% confidence interval 5.2-20.7), parasitaemia (1.6, 1.2-2.2), or both at the same time (4.2, 2.1-8.4) than were children who did not meet the definition. Children who satisfy the malaria and pneumonia clinical definitions need treatment for both disorders. Scarce diagnostic methods, especially microscopy, are needed for more specific treatment of children with fever and cough.

Algorithms↗
PubMed1992

Imported leprosy in the United States, 1978 through 1988: an epidemic without secondary transmission.

OBJECTIVES: Leprosy remains a major health problem in many regions of the world. In the United States, although leprosy continues to be reported, approximately 90% of cases are imported (i.e., occur among immigrants and refugees). An increase in imported cases began in 1978. This study was conducted to analyze this trend and to characterize the contributing cases. METHODS: Centers for Disease Control leprosy surveillance data from 1971 through 1988 were analyzed. RESULTS: The number of imported cases reported annually was relatively constant from 1971 through 1977 (mean = 119 per year), increased to 307 in 1985, and then decreased to 102 in 1988. Of the 957 excess cases reported from 1978 through 1988, 73.4% were among persons from Southeast Asia, including 51.3% from Vietnam, Cambodia, and Laos (Indochina). There was no coincident increase in indigenous cases of leprosy; the mean annual number of such cases was 17.7 (range = 10 to 29). Leprosy remains endemic in Texas, Hawaii, Louisiana, and possibly California. CONCLUSIONS: An epidemic of imported leprosy began in the United States in 1978, peaked in 1985, and ended by 1988. This increase was primarily due to cases among refugees from Indochina and was limited by a decrease in the influx of Indochinese refugees in the mid-1980s. There is no evidence that these cases resulted in transmission in the United States.

Adult↗
PubMed1991

Co-trimoxazole for childhood febrile illness in malaria-endemic regions.

The efficacy of co-trimoxazole for the treatment of Plasmodium falciparum parasitaemia in children younger than 5 years of age was evaluated in Malawi. 46 children with P falciparum parasitaemia, 37% of whom also met clinical criteria for a diagnosis of acute lower respiratory tract infection, were treated with 20 mg/kg co-trimoxazole twice daily for five days. Parasitaemia (mean clearance time 2.7 days) and symptoms were rapidly abolished and improvement was maintained during follow-up for 14 days. Co-trimoxazole may be an effective single treatment for febrile illness in young children in areas where malaria is endemic, resources are few, and diagnosis must rely on clinical findings alone.

Acute Disease↗
PubMed1990

The role of human immunodeficiency virus infection in pneumococcal bacteremia in San Francisco residents.

Human immunodeficiency virus (HIV) is an important risk factor for invasive pneumococcal disease, but information on clinical course and infecting serotypes is limited. To help develop strategies to reduce the morbidity due to invasive pneumococcal disease, episodes of pneumococcal bacteremia were identified by retrospective review of microbiology records (November 1983-November 1987) at 10 San Francisco hospitals and, for patients 20-55 years old living in San Francisco, HIV antibody status was determined by review of medical records. Pneumococcal isolates from one hospital were serotyped. Of 294 patients with pneumococcal bacteremia identified, 32 (11%) had AIDS at the time pneumococcal bacteremia was diagnosed and another 43 (15%) were HIV-infected but did not have AIDS; 12 HIV-infected patients developed AIDS after the episode of pneumococcal bacteremia. The rate of pneumococcal bacteremia in AIDS patients was estimated to be 9.4/1000 patient-years. Serotypes of 27 (82%) of 33 pneumococcal isolates from HIV-infected patients and 107 (90%) from 119 patients without known HIV infection were among the 23 serotypes included in the currently available polysaccharide vaccine. The rate of pneumococcal bacteremia is approximately 100-fold greater in AIDS patients in San Francisco than rates reported before the AIDS epidemic, but more than half the episodes of pneumococcal bacteremia in HIV-infected patients occurred in patients without AIDS. Data on pneumococcal serotypes causing invasive disease in HIV-infected patients suggest that the current pneumococcal vaccine, if effective in this population, could provide significant protection against pneumococcal disease.

Acquired Immunodeficiency Syndrome↗
PubMed1990

A rural outbreak of Legionnaires' disease linked to visiting a retail store.

Between May 7 and June 7, 1986, 27 residents of a rural county in Maryland developed legionellosis, and two died. Legionella pneumophila serogroup 1 was cultured from the sputum of two patients and identified in lung tissue of a third patient by direct fluorescent antibody staining. An additional 11 patients had four-fold rises in antibody titer to L. pneumophila, and 13 had single titers greater than or equal to 1:256. To determine risk factors for disease, we performed a case-control study. Twelve of 16 case-patients reported visiting store A in the two weeks before onset of illness compared with four of 28 control-patients. A serologic survey of employees showed that employees of store A were 3.63 times more likely than control employees to have titers of antibody to L. pneumophila greater than or equal to 1:256 (95% confidence intervals 0.8, 16.7). Cultures of soil specimens, samples of water from the hot water system of store A and from stagnant ponds near store A collected five weeks after the end of the outbreak were negative for Legionella species. Store A was adjacent to a site of excavation and construction during May 1986, when the community was experiencing an extended drought. This investigation suggests that exposure to excavation and construction activity may be a risk factor for legionellosis.

Adult↗