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Onychomycosis

Definition:
Onychomycosis (also known as “dermatophytic onychomycosis,” “ringworm of the nail,” and “tinea unguium”) means fungal infection of the nail.  It is the most common disease of the nails and constitutes about a half of all nail abnormalities.

Click to see the picture

This condition may affect toenails or fingernails, but toenail infections are particularly common. The prevalence of onychomycosis is about 6-8% in the adult population.

Clasification:
There are four classic types of onychomycosis:

*Distal subungual onychomycosis is the most common form of tinea unguium, and is usually caused by Trichophyton rubrum, which invades the nail bed and the underside of the nail plate.

Click to see the picture

*White superficial onychomycosis (WSO) is caused by fungal invasion of the superficial layers of the nail plate to form “white islands” on the plate. It accounts for only 10 percent of onychomycosis cases. In some cases, WSO is a misdiagnosis of “keratin granulations” which are not a fungus, but a reaction to nail polish that can cause the nails to have a chalky white appearance. A laboratory test should be performed to confirm.

*Proximal subungual onychomycosis is fungal penetration of the newly formed nail plate through the proximal nail fold. It is the least common form of tinea unguium in healthy people, but is found more commonly when the patient is immunocompromised.

*Candidal onychomycosis is Candida species invasion of the fingernails, usually occurring in persons who frequently immerse their hands in water. This normally requires the prior damage of the nail by infection or trauma.

Symptoms:
The nail plate can have a thickened, yellow-brown , or cloudy appearance. The nails can become rough and crumbly  , or can separate from the nail bed. This thickening, discolouration and disfigurement are clearly visible.There is usually no pain or other bodily symptoms, unless the disease is severe.

Dermatophytids are fungus-free skin lesions that sometimes form as a result of a fungus infection in another part of the body. This could take the form of a rash or itch in an area of the body that is not infected with the fungus. Dermatophytids can be thought of as an allergic reaction to the fungus. People with onychomycosis may experience significant psychosocial problems due to the appearance of the nail. This is particularly increased when fingernails are affected.

The effects of onychomycosis aren’t simply cosmetic. A thickened nail may limit usual activities. It may press on the inside of footwear, for example, causing discomfort and pain. This in turn can cause problems when walking, and reduce mobility.

Causes:
Onychomycosis is caused by 3 main classes of organisms: dermatophytes (fungi that infect hair, skin, and nails and feed on nail tissue), yeasts, and nondermatophyte molds. All 3 classes cause the same symptoms, so the appearance of the infection does not reveal which class is responsible for the infection. Dermatophytes (including Epidermophyton, Microsporum, and Trichophyton species) are, by far, the most common causes of onychomycosis worldwide. Yeasts cause 8% of cases, and nondermatophyte molds cause 2% of onychomycosis cases.

•The dermatophyte Trichophyton rubrum is the most common fungus causing distal lateral subungual onychomycosis (DLSO) and proximal subungual onychomycosis (PSO).

•The dermatophyte Trichophyton mentagrophytes commonly causes white superficial onychomycosis (WSO), and more rarely, WSO can be caused by species of nondermatophyte molds.

•The yeast Candida albicans is the most common cause of chronic mucocutaneous candidiasis (disease of mucous membrane and regular skin) of the nail.

Risk Factors:
Risk factors for onychomycosis include family history, advancing age, poor health, trauma, living in a warm climate, participation in fitness activities, immunosuppression (can occur from HIV or certain drugs), bathing in communal showers (such as at a gym), and wearing shoes that cover the toes completely and don’t let in any airflow.

People with diabetes are at greater risk, as are those whose immune system is suppressed.

It’s possible to reduce your risk of onychomycosis by practising good nail care. This reduces the risk of other nail and foot-related problems, too.

Click to see more

Diagnosis:
Onychomycosis (OM) can be identified by its appearance. However, other conditions and infections can cause problems in the nails that look like onychomycosis. OM must be confirmed by laboratory tests before beginning treatment, because treatment is long, expensive, and does have some risks.

•A sample of the nail can be examined under a microscope to detect fungi. See Anatomy of the Nail for information on the parts of the nail.

•The nails must be clipped and cleaned with an alcohol swab to remove bacteria and dirt.

•If the doctor suspects distal lateral subungual onychomycosis (DLSO), a sample (specimen) should be taken from the nail bed to be examined. The sample should be taken from a site closest to the cuticle, where the concentration of fungi is the greatest.

•If proximal subungual onychomycosis (PSO) is suspected, the sample is taken from the underlying nail bed close to the lunula.

•A piece of the nail surface is taken for examination if white superficial onychomycosis (WSO) is suspected.

•To detect candidal onychomycosis, the doctor should take a sample from the affected nail bed edges closest to the cuticle and sides of the nail.

•In the laboratory, the sample may be treated with a solution made from 20% potassium hydroxide (KOH) in dimethyl sulfoxide (DMSO) to rule out the presence of fungi. The specimen may also be treated with dyes (a process called staining) to make it easier to see the fungi through the microscope.

•If fungi are present in the infected nail, they can be seen through a microscope, but the exact type (species) cannot be determined by simply looking through a microscope. To identify what exactly is causing onychomycosis, a technique called culturing is used. Using a fungal culture to identify the particular fungus is important because regular therapy may not work on nondermatophyte molds.

…#The infected nail is scraped or clipped.

…#The scrapings or clippings are crushed and put into containers. Any fungus in the samples can grow in the laboratory in these special containers.

…#The species of fungus can be identified from the cultures grown in the lab.

Click to see the pictures

Treatment:
Medications
In the past, medicines used to treat onychomycosis (OM) were not very effective. OM is difficult to treat because nails grow slowly and receive very little blood supply. However, recent advances in treatment options, including oral (taken by mouth) and topical (applied on the skin or nail surface) medications, have been made. Newer oral medicines have revolutionized treatment of onychomycosis. However, the rate of recurrence is high, even with newer medicines. Treatment is expensive, has certain risks, and recurrence is possible.

•Topical antifungals are medicines applied to the skin and nail area that kill fungus.

…#These topical agents should only be used if less than half the nail is involved or if the person with onychomycosis cannot take the oral medicines. Medicines include amorolfine (approved for use outside the United States), ciclopirox olamine (Penlac, which is applied like nail polish), sodium pyrithione, bifonazole/urea (available outside the United States), propylene glycol-urea-lactic acid, imidazoles, such as ketoconazole (Nizoral Cream), and allylamines, such as terbinafine (Lamisil Cream).

…#Topical treatments are limited because they cannot penetrate the nail deeply enough, so they are generally unable to cure onychomycosis. Topical medicines may be useful as additional therapy in combination with oral medicines.

•Newer oral medicines are available. These antifungal medicines are more effective because they go through the body to penetrate the nail plate within days of starting therapy.

…#Newer oral antifungal drugs terbinafine (Lamisil Tablets) and itraconazole (Sporanox Capsules) have replaced older therapies, such as griseofulvin, in the treatment of onychomycosis. They offer shorter treatment periods (oral antifungal medications usually are administered over a 3-month period), higher cure rates, and fewer side effects. These medications are fairly safe, with few contraindications (conditions that make taking the medicine inadvisable), but they should not be taken by patients with liver disease or heart failure. Before prescribing one of these medications, doctors often order a blood test to make sure the liver is functioning properly. Common side effects include nausea and stomach pain.

…#Fluconazole (Diflucan) is not approved by the Food and Drug Administration (FDA) for treatment of onychomycosis, but it may be an alternative to itraconazole and terbinafine.

•To decrease the side effects and duration of oral therapy, topical and surgical treatments may be combined with oral antifungal management.
Surgery

Surgical approaches to onychomycosis treatment include surgically or chemically removing the nail (nail avulsion or matrixectomy).

•Removing the nail plate (fingernail or toenail) is not effective treatment on its own. This procedure should be considered an adjunctive (additional) treatment combined with oral therapy.

•A combination of oral, topical, and surgical therapy can increase the effectiveness of treatment and reduce the cost of ongoing treatments.

Research:
Most drug development activities are focused on the discovery of new antifungals and novel delivery methods to promote access of existing antifungal drugs into the infected nail plate. Active clinical trials investigating onychomycosis:

Phase III
*A topical treatment, AN2690, is being developed by Anacor Pharmaceuticals.  It is active against Trichophyton species.

*A medicinal nail lacquer, MycoVa from Apricus Biosciences,[40] contains terbinafine as the active ingredient and a permeation enhancer DDAIP which facilitates the delivery of the drug into the nail bed where the fungus resides.

*A comparison of delivery methods for itraconzole

*Safety and tolerability of topical terbinafine

*Laser-based treatments

*Topical IDP-108

*Bifonazole cream application after nail ablation with urea paste

Phase II
*Posaconazole, taken orally.

*A topical treatment, NB-002, is being developed by NanoBio Corporation. It has completed Phase II trials

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
http://en.wikipedia.org/wiki/Onychomycosis
http://www.emedicinehealth.com/onychomycosis/page7_em.htm
http://www.bbc.co.uk/health/physical_health/conditions/onychomycosis1.shtml

http://www.aafp.org/afp/2001/0215/p663.html

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Pill With a Will

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Patients often fail to take their medication properly. Technology steps in with some ideas. Amber Dance reports .

Did you take your medicine today?” Soon, patients won’t have to rely on their memories for the answer. Scientists are developing tablets and capsules that track when they’ve been popped, turning the humble pill into a high-tech monitoring machine. The goal: new devices to help people take their medicines on time and improve the results of clinical trials for new drugs.
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Doctors can already prescribe pills that release drugs slowly or at a specific time. They even have camera pills that take snaps of their six to 12-metre journey through the gastrointestinal tract. The new pills tote microchips that make them even cleverer: they will report back to a recorder or smart phone exactly what kind and how much medicine has gone down the hatch and landed in the stomach. Someday they may also report on heart rate and other bodily data.

This next generation of pills is all about compliance, as it’s termed in doctor-speak — the tendency of patients to follow their doctors’ instructions (or not). According to the World Health Organisation (WHO), half of patients don’t take their pills properly. They skip doses, take the wrong amount at the wrong time or simply ignore prescriptions altogether.

The most common reason for medication mistakes is forgetfulness, particularly among the elderly. “The number of prescriptions they get is mind-boggling,” says Jill Winters, dean, Columbia College of Nursing in Milwaukee, Wisconsin. According to a 2004 report by the Centers for Disease Control and Prevention and the Merck Institute of Aging and Health, the average 75-year-old takes five different drugs.

Often, occasional lapses don’t matter. Smart pills like these are “not for your aspirin or even simple antibiotics,” says Maysam Ghovanloo, an electrical engineer at the Georgia Institute of Technology in Atlanta. The new technology is aimed at time-sensitive or costly medications.

For certain medications, not taking every pill can have serious consequences. For example, those mentally ill may require regular treatment to stay stable. Chemotherapy drugs and antibiotics for treating tuberculosis (TB) are also time-sensitive.

Blood pressure (BP) medication works only when taken on a regular basis; suddenly stopping it can cause the BP to skyrocket, says Daniel Touchette, a pharmacist and researcher at the University of Illinois, Chicago.

With drugs for transplant patients, a person who misses a dose risks rejection of the new organ. Novartis International AG, based in Basel, Switzerland, is developing pills for transplant recipients; the pills communicate with a patch on the skin when they reach the stomach.

And in the case of TB, treatment requires a six-month course of antibiotics that come with side effects such as nausea and heartburn. Many people don’t understand why they have to keep taking the unpleasant drugs once they feel better — but going off the medication may make patients contagious again and allow drug-resistant TB to develop.

Yet another arena where compliance is crucial is clinical drug trials. Drugmakers can only be sure their medicine works if they’re sure subjects are actually taking it as directed. For now, experimenters rely on diaries where participants record their medication use. But people may fudge the data, not wanting to admit they dropped a pill down the drain or forgot to take it for a few days. To account for those who miss their medicines, firms have to spend extra — trials cost hundreds of millions of dollars — for larger trials just so enough people will actually take the drug.

Technology already offers some solutions, with mobile phone reminders and pill bottles that record when they’re opened. But none of these actually confirms that the medicine has been swallowed.

Ghovanloo hopes to improve compliance with a necklace that records every time a special pill slides down the esophagus. He calls it MagneTrace. By sounding an alarm or sending a mobile phone message, the necklace also would inform the wearer when it’s time for another dose. Caretakers or doctors could monitor the signals too.

The system works by radio-frequency identification, or RFID. Three magnets on a choker-type necklace act like pillars, continually surveying the neck. The pill contains an RFID chip to communicate with the magnets. When Ghovanloo tested the system in an artificial neck made of PVC pipe, the necklace detected 94 per cent of pills passing through it. He hopes to get that number up to 99 per cent and is adding a microchip that will also transmit information about the specific drug taken and its dose.

Ghovanloo coats the chips with a non-reactive material so that after the medicine dissolves, the hardware simply passes through and out of the digestive tract. However, Ghovanloo says he needs make the design more fashionable. “Right now, it’s not something that a lady would be willing to wear,” he says. For men, he might embed the device in a shirt collar.

Rizwan Bashirullah, an electrical engineer at the University of Florida in Gainesville, is also working on pills that will confirm they’ve been taken. “They’re essentially little stickers,” he says of his technology, called the ID-Cap. Gainesville-based eTect is developing the product.

Each sticker contains three components: a microchip, an antenna and an acid sensor. Altogether it’s approximately half the size of a postage stamp, says eTect President Eric Buffkin. The sensor activates the device when it lands in the acid environment of the stomach, and the chip uses the antenna to send electronic signals directly through the body’s tissues to a receiver, worn on a wristband. The silver antenna and sensor dissolve into safe components; these and the microchip, about as big as a grain of sand, are flushed out of the gut. Over the next year, the company plans to test the capsule for safety in animals and people, Buffkin says.

Source : Los Angerles Times

Published by The Telegraph ( Kolkata India)

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Epididymitis

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Definition:-
Epididymitis is a medical condition in which there is inflammation of the epididymis (a curved structure at the back of the testicle in which sperm matures and is stored). This condition may be mildly to very painful, and the scrotum (sac containing the testicles) may become red, warm and swollen. It may be acute (of sudden onset) or rarely chronic.
…..Click to see the picture..

click to see the pictures

1: Epididymis

2: Head of epididymis
3: Lobules of epididymis
4: Body of epididymis
5: Tail of epididymis
6: Duct of epididymis
7: Deferent duct (ductus deferens or vas
Epididymitis is the most frequent cause of sudden scrotal pain. In contrast with men who have testicular torsion, the cremaster reflex (elevation of the testicle in response to stroking the upper inner thigh) is not altered. If the diagnosis is not entirely clear from the patient’s history and physical examination, a Doppler ultrasound scan can confirm increased flow of blood to the affected epididymis.

Infection is the most common cause. In sexually active men, Chlamydia trachomatis is the most frequent causative microbe, followed by E. coli and Neisseria gonorrhoeae. In children, it may follow an infection in another part of the body (for example, a viral illness), or there may be an associated urinary tract anomaly. Another cause is sterile reflux of urine through the ejaculatory ducts. Antibiotics may be needed to control a component of infection. Treatment otherwise comprises pain killers or anti-inflammatory drugs and bed rest if necessary, and symptom control by resting the scrotum in a supported position.
Males of any age can get epididymitis, but it’s most common in men between the ages of 20 and 39.

Classification
Epididymitis can be classified into acute and chronic.

Acute Epididymis:>-click & see    .Swelling in a patient with epididymitis

1. Ductus Deferens
2. Epididymis
3. Testicle

Chronic epididymitis..>.click & see
Chronic epididymitis is epididymitis which ensues for more than six weeks. Chronic epididymitis is characterised by inflammation even when there is no infection present. Tests are needed to distinguish chronic epididymitis from a range of other disorders that can cause constant scrotal pain. These include testicular cancer, enlarged scrotal veins (varicocele) or a cyst within the epididymis. As well, the nerves in the scrotal area are connected to those of the abdomen, sometimes causing pain similar to a hernia (see referred pain). This condition can develop even without the presence of the previously described known causes.

Typically, a second, longer round of treatment is used. It is believed that the hypersensitivity of certain structures, including nerves and muscles, may cause or contribute to chronic epididymitis. A procedure called a cord block is a last measure. This consists of an injection into the nerve that traces along the epididymis. The injection is a compound of several medications including a steroid, pain killers, and a high dose of an anti-inflammatory. This treatment can quell the pain for 2–3 months in ideal conditions. Some patients may only experience an even shorter duration of 2–3 days, while the fortunate ones in rare occasions are never bothered again. This procedure would of course have to be repeated when necessary, until the problem goes away completely, or until the routine is simply too bothersome. As a last resort, a patient may then decide to have the epididymis completely removed.

Symptoms:–
Epididymitis symptoms depend on the cause. They can include:

#A tender, swollen, red or warm scrotum
#Testicle pain and tenderness, usually on one side — the pain may get worse when you have a bowel movement
#Painful urination or an urgent or frequent need to urinate
#Painful intercourse or ejaculation
#Chills and a fever
#A lump on the testicle
#Enlarged lymph nodes in the groin (inguinal nodes)
#Pain or discomfort in the lower abdomen or pelvic area
#Discharge from the penis
#Blood in the semen

Causes:-
#Infection is the most common cause of epididymitis. The bacteria in the urethra back-track through the urinary and reproductive structures to the epididymis. There can be associated urethritis (inflammation of the urethra). Rarely, the infection reaches the epididymis via the bloodstream.

In sexually active men, Chlamydia trachomatis is responsible for two-thirds of cases, followed by Neisseria gonorrhoeae and E. coli (or other bacteria that cause urinary tract infection). Particularly among men over age 35 in whom the cause is E. coli, epididymitis is commonly due to urinary tract obstruction. Less common microbes include Ureaplasma, Mycobacterium, and cytomegalovirus, or Cryptococcus in patients with HIV infection. E. coli is more common in boys before puberty, the elderly and homosexual men.

#Other infections. Boys, older men and homosexual men are more likely to have epididymitis caused by a non-sexually transmitted bacterial infection. For men and boys who’ve had urinary tract infections or prostate infections, bacteria may spread from the infected site to the epididymis. Rarely, epididymitis is caused by a fungal infection.

#Non-infectious causes are also possible. Reflux of sterile urine (urine without bacteria) through the ejaculatory ducts may cause inflammation with obstruction. In children, it may be a response following an infection with enterovirus, adenovirus or Mycoplasma pneumoniae.

#The heart medication amiodarone. In some cases, this anti-arrhythmic medication causes inflammation of the epididymis. Epididymitis caused by amiodarone is treated by temporarily discontinuing the drug or reducing the dose.

#Tuberculosis. In some cases, tuberculosis can cause epididymitis.

#Urine in the epididymis. Known as chemical epididymitis, this occurs when urine flows backward into the epididymis. It may occur with heavy lifting or straining.

Epididymitis can also be caused by genito-urinary surgery, including prostatectomy and urinary catheterization. Congestive epididymitis is a long-term complication of vasectomy. Chemical epididymitis may also result from drugs such as amiodarone.

Diagnosis:-
Epididymitis can be hard to distinguish from testicular torsion. Both can occur at the same time. A urologist may need to be consulted.

Epididymitis usually has a gradual onset. On physical examination, the testicle is usually found to be in its normal vertical position, of equal size compared to its counterpart, and not high-riding. Typical findings are redness, warmth and swelling of the scrotum, with tenderness behind the testicle, away from the middle (this is the normal position of the epididymis relative to the testicle). The cremasteric reflex (if it was normal before) remains normal. This is a useful sign to distinguish it from testicular torsion. If there is pain relieved by elevation of the testicle, this is called Prehn’s sign, which is however non-specific.

Analysis of the urine may or may not be normal. Before the advent of sophisticated medical imaging techniques, surgical exploration was the standard of care. Nowadays, color Doppler ultrasound is the preferred test. It can demonstrate increased blood flow (also compared to the normal side), as opposed to testicular torsion. Nuclear testicular blood flow testing is rarely used.

Additional tests may be necessary to identify underlying causes. In younger children, a urinary tract anomaly is frequently found. In sexually active men, tests for sexually transmitted diseases may be done. These may include microscopy and culture of a first void urine sample, Gram stain and culture of fluid or a swab from the urethra, nuclear acid amplification tests (to amplify and detect microbial DNA or other nucleic acids) or tests for syphilis and HIV.

Treatment:-
Antibiotics are used if an infection is suspected. Fluoroquinolones are no longer recommended for sexually transmitted infections, because of the resistance of Neisseria gonorrhoeae . A cephalosporin (such as ceftriaxone) combined with doxycycline is an alternative. Azithromycin can be used for susceptible strains.

For cases caused by enteric organisms (such as E. coli), ofloxacin or levofloxacin are recommended.

In children, quinolones and doxycycline are best avoided. Since bacteria that cause urinary tract infections are often the cause of epididymitis in children, co-trimoxazole or suited penicillins (for example, cephalexin) can be used. If there is a sexually transmitted disease, the partner should also be treated.

Household remedies such as elevation of the scrotum and cold compresses applied regularly to the scrotum may relieve the pain. Painkillers or anti-inflammatory drugs are often necessary. Hospitalisation is indicated for severe cases, and check-ups can ensure the infection has cleared up. Surgery is rarely necessary, except, for example, in those rare instances where an abscess forms.

Home Remedies & Change of Lifestyle:-
Having epididymitis usually means you’re experiencing considerable pain and discomfort. To ease your symptoms, you may  try  the advices:

#Rest in bed. Depending on the severity of your discomfort, you may want to stay in bed one or two days.

#Elevate your scrotum. While lying down, place a folded towel under your scrotum.

#Wear an athletic supporter. A supporter provides better support than boxers do for the scrotum.

#Apply cold packs to your scrotum. Wrap the pack in a thin towel and remove the cold pack every 30 minutes or so to avoid damaging your skin.

#Don’t have sex until your infection has cleared up. Ask your doctor when you can have sex again.

Risk factors:-

Sexually transmitted epididymitis
Several factors increase your risk of getting epididymitis caused by an STD, including:

#High-risk sexual behaviors, such as having multiple sex partners, having sex with a partner with an STD and having sex without a condom.

#Personal history of an STD. You’re at increased risk of an infection that causes epididymitis if you’ve had an STD in the past.
Non-STD infections:-
Several things increase your risk of epididymitis caused by an infection other than an STD, including:

#Past prostate or urinary tract infections. Chronic urinary tract infections or prostate infections are linked to bacterial infections that can cause epididymitis.

#An uncircumcised penis or an anatomical abnormality of the urinary tract. These conditions increase your risk of epididymitis caused by a bacterial infection.

#Medical procedures that affect the urinary tract. Procedures such as surgery or having a urinary catheter or scope inserted into the penis can introduce bacteria into the genital-urinary tract, leading to infection.

#Prostate enlargement. Having an enlarged prostate that obstructs bladder function and causes urine to remain in the bladder puts you at higher risk of bladder infections, which increases the risk of epididymitis.

Epididymitis may eventually cause:

#Scrotal abscess, when infected tissue fills with pus

#Chronic epididymitis, which can occur when untreated acute epididymitis leads to recurrent episodes

#Shrinkage of the affected testicle (atrophy)

#Reduced fertility, but this is rare

If the condition spreads from your epididymis to your testicle, the resulting condition is known as epididymo-orchitis. Signs, symptoms and treatment options are basically the same as they are for epididymitis.

Prevention:-
If your epididymitis was caused by an STD, your partner also will need treatment. If your partner doesn’t get treatment, you may contract the STD again. Safer sexual practices, such as monogamous sex and condom use, help protect against STDs that can cause epididymitis.

If you have recurrent urninary tract infections or other risk factors for epididymitis, your doctor may discuss with you other ways to prevent epididymitis from recurring.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.


Resources:
http://en.wikipedia.org/wiki/Epididymitis
http://www.mayoclinic.com/health/epididymitis/DS00603

 

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Swine Flu Vaccine May Come Shortly

Federal officials said it would take until January, or late November at the earliest, to make enough vaccine to protect all Americans from a  possible epidemic of swine flu. And beyond the US and a few other countries that also make vaccines, some experts said it could take years to produce enough swine flu vaccine to satisfy global demand.

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Producing swine flu vaccine might interfere with production of the seasonal flu vaccine for next winter. “We would have to most likely make a compromise,” said Andrin Oswald, chief executive of the vaccine division at the drug maker Novartis.

But Robin Robinson, who runs the emergency preparation research program for Department of Health and Human Services, said most firms would have finished producing the bulk of seasonal vaccine by June. If production of swine flu vaccine were to start after that, the first 50 million to 80 million doses would be available by September, Robinson said.

You may click to see:-> H1N1 virus gone viral: Swine flu updates and resources online

Sources: The Times Of India

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