It's International Left-Handers Day, Why Are People Left-Handed?

It's International Left-Handers Day, Why Are People Left-Handed?
It’s International Left-Handers Day, so it’s time to give left-handers some overdue appreciation.

There was once a time (a long time ago), when people believed that being left-handed meant a person was more prone to “dealings with the devil” and that the trait should be corrected, according to the New York Times. Thankfully, the prejudice is gone, but people are still curious—why do some kids grow up left-handed versus right-handed?

Numbers suggest that about 90% of people are right-handed, and 10% use their left hand predominantly. Notable left-handers include President Barack Obama, Bill Gates and Oprah Winfrey. Some researchers believe that being left-handed is at least partially related to genetics, though it’s likely not the full story.

One 2013 study, published in the journal PLOS Genetics, identified genes and gene mutations that can influence the development of “left-right asymmetry in the body and brain,” Smithsonian.com reports. It’s possible that some of these genes are related to handedness. But some experts say they think genetics is responsible only 25% of the time, and that handedness may be pretty random. As the Atlantic reports, some researchers believe that being left-handed may be a trait that has continued through time because it gives some people an advantage during fighting.

While experts are still sorting out the reasons, scientists have shown that there doesn’t appear to by any differences between right and left-handed people when it comes to personality traits like extra version, agreeableness, conscientiousness, emotionality and openness to experience.

While there are advantages to being left-handed, especially when it comes to sports, there’s also the disadvantages (like getting elbowed during dinner). So make sure that left-handed person in your life is having a happy holiday.

By - Alexandra Sifferlin - time.com
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Immunological basis of Vaccination

Immunological basis of Vaccination
Introduction

Antibody Antigen Action
Immunization aims to artificially induce immunity against disease. This may be active, whereby the immune system is recruited to provide protection against the disease or infection, or passive, where exogenous protection is provided, albeit temporarily.

Normal immune response

The immune system provides protection against infectious agents. Classically, the system is divided into the innate immune system and the specific or acquired immune system. The innate immune system consists of cells (monocytes, macrophages, dendritic cells, neutrophils, eosinophils and natural killer cells) and molecules (complement, cytokines, chemokines etc) while the specific immune system is composed of lymphocytes. These include B lymphocytes producing antibody, and subsets of T lymphocytes including CD4+ T lymphocytes and CD8+ cytotoxic T lymphocytes. The CD4+T lymphocytes are further divided into TH1 cells producing inflammatory cytokines such as interferon Ɣ (IFN Ɣ ) and TH2 cells, as well as regulatory T cells and TH17 cells1,2.

The innate immune system recognizes the pathogen and subsequently activates the specific immune system3. Then these two systems act in concert against the infection. Pathogens that enter the body through skin/ mucous membranes are taken up by resident antigen presenting cells in these tissues. The main antigen presenting cell (APC) is the dendritic cell, the macrophage being another APC. The antigen presenting cells and molecules of the innate immune system have receptors (pattern recognition receptors) that can recognize conserved foreign molecules found only on pathogens (pathogen associated molecular patterns). Recognition is followed by activation of these cells and molecules. Dendritic cells along with the macrophage, found in the skin and othersites are crucial in the subsequent activation of the specific immune system1. The dendritic cell senses potential ‘danger’ when recognizing pathogen associated molecular patterns. Recognition is followed by uptake of the pathogen and activation of the dendritic cell and other antigen presenting cells.

This leads to,

• production of cytokines and chemokines resulting in inflammation
• up-regulation of co-stimulators on the antigen presenting cells essential for successful antigen presentation to T cells
• localization of the pathogen containing antigen presenting cells to the draining lymph node.

Blood borne pathogens are directly taken up by dendritic cells in the white pulp of the spleen.

During this process, the dendritic cells internalize the pathogens and present peptides derived from the microorganisms, in conjunction with major histocompatibility complex (MHC) class II molecules on its surface. Viruses infecting dendritic cells produce virus coded peptides in the cytoplasm. These peptides are presented in conjunction with MHC Class I molecules.

T and B cells have receptors that recognize antigen. Most circulating lymphocytes recognize non self-antigen2. Lymphocytes circulate in the body between blood and peripheral lymphoid tissue (cell trafficking). Activated dendritic cells present peptides derived from pathogens, in conjunction with MHC Class II molecules to CD4+ T cells in the T cell areas of the lymph nodes and spleen. The CD4+ T cell will be activated only if second signals are provided by co-stimulatory molecules on the surface of dendritic cells. These co-stimulators are up regulated only if pathogen associated molecular patterns are recognized by the dendritic cells. As these patterns are only found on pathogens, the dendritic cell will activate non-self reacting CD4 +T cells. Depending on the pathogen and the cytokine milieu around the reaction, the CD4+ T cells become either armed effector TH1 or TH2 cells or memory cells (2).

Dendritic cells which are activated by microorganisms such as M. tuberculosis produce cytokines that switch a naïve CD4+ T cell to an activated TH1 cell, while helminths and some bacterial pathogens induce a TH2 response. TH1 cells produce cytokines (IL2, IFN Ɣ) that activate CD8+cytotoxic T lymphocytes, macrophages and B lymphocytes, while TH2 cells activate B cells by producing IL4, 6 and 13.

B cells that recognize protein antigens need help from CD4+ T cells (TH1 and TH2) to produce antibody. The initial B cell response takes place extra follicularly (outside the germinal centre)2 and produces low affinity IgM and a small amount of IgG. This occurs within a few days of the infection/immunization and is short lived.This is followed by a response in the germinal centre. B cells move into the germinal centre and encounter their cognate antigen found on the surface of follicular dendritic cells. The B cell proliferates, producing a clone of daughter cells whose antigen binding receptors (immunoglobulin molecules found on the surface of the B cell) have undergone point mutations (somatic hypermutation). These mutations are confined to the antigen binding site of the receptor. B cells with receptors with a greater fit (affinity) would bind to the cognate antigen and survive, while those with a weaker fit would undergo apoptosis. The surviving B cells would differentiate into plasma cells or memory B cells. With time, high affinity (affinity maturation) IgG, IgA and IgE antibodies are produced (isotype switching) by plasma cells, some being long lived. Memory B cells are capable of producing high affinity, class switched antibody with great rapidity, after re-exposure to the same microorganism. Affinity maturation, isotype switching and memory need T cell help and are hallmarks of antibody responses to protein antigens. T cell help is provided in germinal centers by follicular helper T cells (TfH cells). This response takes 10-14 days to appear and terminates in 3-6 weeks. Peak antibody concentrations occur 4-6 weeks after primary immunization.

Polysaccharide epitopes such as the capsules of S pneumoniae and H influenzae, do not activate CD4+ T cells (T independent responses) (2). A subset of B cells in the marginal zone of the spleen, assisted by marginal zone macrophages, produce low affinity mainly IgM antibodies and medium affinity IgG (T independent antibodies). Polysaccharides arepoorly immunogenic in children under 2 years, till maturation of the marginal zone. As T independent responses do not produce memory cells, subsequent re-exposure evokes a repeat primary response. In some instances, revaccination with certain bacterial polysaccharides may even induce lower antibody responses than the first immunization, aphenomenon referred to as hyporesponsiveness (4).

Antibodies provide protection against extra cellular organisms, such as capsulate bacteria or viruses during an extra cellular phase. IgA provides mucosal immunity, preventing infection by bacteria and viruses through the mucosa; IgM provides quick responses to blood borne pathogens while IgG protects blood and tissues.

Protection against intracellular microorganisms is through cell mediated immunity. Viruses infect cells and produce virus derived proteins in the cytoplasm. Peptides derived from these proteins are presented on MHC Class I molecules by all nucleated cells. These are recognized by previously activated cytotoxic T lymphocytes and the infected cell is destroyed. Microorganisms residing in intracellular vesicles of macrophages such as M tuberculosis, are dealt with by TH1 cells activating the macrophage, resulting in intracellular killing of the bacteria.

Vaccines

Different types of vaccines have been produced (5).

• Live attenuated
• Killed/inactivated
• Subunit
• Recombinant
• Conjugate

Immune response to vaccines

Vaccine induced immunity is mainly due to IgG antibodies. Antibodies are capable of binding toxins and extracellular pathogens.The quality ofthe antibody (avidity), the persistence of the response and generation of memory cells capable of a rapid response to reinfection are key determinants of vaccine effectiveness. For protection against bacterial diseases that result from the production of toxins (tetanus and diphtheria) the presence of long lasting antitoxin antibody and memory B cells are necessary, ensuring the presence of antitoxin antibody at the time of exposure to the toxin. With viruses such as hepatitis B, undetectable antibody titers are seen in many vaccine recipients but due to the long incubation period of the virus, memory B cells can be reactivated in time to combat the infection.

For infections which originate at mucosal sites, transudation of serum IgG will limit colonization and invasion. This is due to pathogens being prevented from binding to cells and receptors in the mucosa. Transudation of IgG is not seen with polysaccharide vaccines. If the pathogens breach the mucosa IgG in serum will neutralize the pathogen, activate complement and facilitate phagocytosis, thereby preventing spread. Some vaccines (eg. oral polio, rotavirus and nasal influenza) will stimulate production of IgA antibody at mucosal surfaces and thereby limit virus shedding. Live, inactivated and subunit vaccines evoke a T dependent response, producing high quality antibody and memory B cells. Polysaccharide vaccines (eg. pneumococcal 23 valent vaccine) evoke a T independent response4 where the IgG produced is of poor quality (affinity) and memory B cells are not produced. However, conjugation of the polysaccharide with a protein (conjugate vaccines) evokes a T dependent response. Inactivated, subunit and conjugate vaccines will only evoke antibodies. Live viral vaccines will in addition activate cytotoxic T lymphocytes. These cytotoxic T lymphocytes limit the spread of infections by killing infected cells and secreting antiviral cytokines.

Antibody responses are ineffective against intracellular organisms such as M. tuberculosis. There is evidence that a CD4+TH1 response, with production of IFN  Ɣ leading to activation of infected macrophages is elicited following BCG vaccination(6).

The quality of the immune response depends on the type of vaccine. Live viral vaccines evoke a strong immune response.

This is due to(7)

• having sufficient pathogen associated molecular patterns to efficiently activate immature dendritic cells, a key requirement for the development of specific immunity.

• the vaccine virus multiplying at the site of inoculation and disseminating widely, and being taken up by dendritic cells at many sites. These dendritic cells are then activated and are carried to many peripheral lymphoid organs, where activation of antigen specific B and T lymphocytes occur. As the immune response occurs at multiple sites, live viral vaccines evoke a strong immuneresponse persisting for decades. Due to the early and efficient dissemination of the virus, the site or route of inoculation does not matter (eg. SC versus IM). BCG vaccine acts similarly, by multiplying at the site of inoculation and at distant sites as well. Non-live vaccines may have enough pathogen associated molecular patterns to activate dendritic cells but in the absence of microbial replication this activation is limited in time and is restricted to the site of inoculation. As the immune response is restricted to the local lymph nodes, it is weaker than with a live vaccine. Therefore, repeated booster doses are necessary. As only the regional nodes are involved, multiple non live vaccines can be given, provided the inoculations are performed at different sites. Booster doses are ineffective with polysaccharide vaccines as memory B cells are not produced.

In addition, the route of inoculation is important. The dermis has many dendritic cells, and for example, the rabies vaccine given intradermally at 1/10th the IM dose can evoke an equally good response. Where the vaccine is not very immunogenic (eg. hepatitis B vaccine), IM injections are preferred over SC7,8 as muscle tissue has many dendritic cells, unlike adipose tissue.

Determinants of primary vaccine response

• Intrinsic immunogenicity of the vaccine.

• Type of the vaccine – Live viral vaccines elicit better responses than non-live vaccines. Non-live vaccines rarely induce high and sustained antibody responses after a single dose. Therefore, primary immunization schedules usually include at least two doses, repeated at a minimum interval of 4 weeks to generate successive waves of B cell responses. Even so, the response usually wanes with time.

• Dose – As a rule, higher doses of non-live antigens, up to a certain threshold, elicit higher primary antibody responses. This may be particularly useful when immunocompetence is limited eg. for hepatitis B immunization of patients with end stage renal failure.

• Nature of the protein carrier.

• Genetic composition of the individual.

• Age – responses at the extremes of age are weaker and less persistent.

Determinants of duration of vaccine response(7)

Plasma cells which produce antibodies are usually short lasting, while a few plasma cells produced in the germinal centre may survive for long periods in the bone marrow. These cells are responsible for the maintenance of protective antibodies for long periods. This occurs most efficiently with live vaccines, less efficiently with non-live vaccines, but not with polysaccharide vaccines. Live viral vaccines are the most efficient at evoking long lasting immune responses that may persist lifelong due to the presence of viral antigens that may regularly activate the immune system.

Interval between doses may be important. Two doses given one week apart may evoke a rapid short lived response, whereas 2 doses 4 weeks apart may be longer lasting. Vaccination at extremes of age or in patients with chronic disease may evoke short lived responses.

Adjuvants (9)

For non-live vaccines, adjuvants are incorporated to provide the ‘danger’ signal to the antigen presenting cells. Adjuvants are also needed to prolong the antigen delivery at the site of inoculation, thereby recruiting more dendritic cells. They should also be non-toxic.

The known adjuvants used in human vaccines are,

• Alum – an aluminum salt-based adjuvant.
• AS04 – a combination adjuvant composed of monophosphoryl lipid A adsorbed to alum.
• Oil-in-water emulsions – such as MF59 and AS03

Summary

All vaccines produce antibodies which can neutralize extracellular pathogens. Conjugate vaccines, toxoids, inactivated vaccines and live attenuated vaccines produce high affinity antibody and memory cells unlike polysaccharide vaccines. Polysaccharide vaccines are made more immunogenic by conjugation with a protein carrier.

Live viral vaccines evoke cytotoxic T lymphocyte responses which act against intracellular pathogens. Similarly, the BCG vaccine activates TH1 cells, whose cytokines help macrophages control M. tuberculosis. Live viral vaccines produce long lasting, even lifelong immunity compared to non-live vaccines.

References

1. Turvey SE, Broide DH. Innate immunity. J Allergy Clin Immunol 2010; 125: S24-32.

2. Bonilla FA, Oettgen HC. Adaptive immunity. J Allergy Clin Immunol 2010; 125: S33-40.

3. Iwasaki A, Medzhitov R. Regulation of adaptive immunity by the innate immune system. Science 2010; 327: 291-95.

4. Pace D. Glycoconjugate vaccines. Biol. Ther 2013: 13(1): 11-33.

5. Pulendran B, Ahmed R. Immunological mechanisms of vaccination. Nat Immunol 2011; 12(6): 509-17.

6. Ritz N, Hanekom WA, Robins-Browne R, Britton WJ, Curtis N. Influence of BCG vaccine strain on the immune response and protection against tuberculosis. FEMS Microbiol Rev 2008; 32: 821-841.

7. Siegrist CA. Vaccine Immunology. In: Plotkin SA, Orenstein W, Offit PA Eds. Vaccine Expert Consult 6th Ed Sauders 2012, p 15-32. 8. de Lalla F, Rinaldi E, Santoro D, et al. Immune response to hepatitis B vaccine given at different injection sites and by different routes: a controlled randomized study. Eur J Epidemiol 1988; 4: 256-8.

9. Alving CR, Peachman KK, Rao M, Reed SG. Adjuvants for human vaccines. Curr Opin Immunol 2012; 24(3): 310-15. Dr Rajiva de Silva Dip. Med. Micro, MD(Micro.) Consultant Immunologist, Medical Research Institute, Colombo
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Precautions and Contraindication before vaccination

Precautions and Contraindication before vaccination
Precautions and Contraindication before vaccination
There are many reasons to avoid or postpone vaccines.Sometimes people may have unreasonable concerns that lead to indecision to get vaccination even when there is no risk.  It is critical for vaccine providers and relevant healthcare workers to distinguish among these different reasons. In this article we try to make rough idea about this facts. Before that lets refresh the terms "Contraindication " and "Precaution ".

A contraindication is a situation in which a drug, such as a vaccine, should not be used because the risk outweighs any potential therapeutic benefit.

A precaution is a condition that may increase the risk of an adverse reaction following immunization or that may compromise the ability of the vaccine to produce immunity. In general, vaccines are deferred when a precaution is present. However, there may be circumstances when the benefits of giving the vaccine outweigh the potential harm, or when reduced vaccine immunogenicity may still result in significant benefit to a susceptible, immuno-compromised host.

1. Vaccines should not be administered
if there was a severe reaction such as anaphylaxis following administration of that particular vaccine or a component of that vaccine.

2. Live vaccines should not be administered
• to a person having a malignancy of the reticulo-endothelial system
• during pregnancy
• if a live vaccine had been administered within one month
• if the person has had blood or blood products including immunoglobulin within three months
• for two weeks after stopping long term oral steroids ( >= 2mg/kg /day prednisolone or equivalent or 20 mg / day for > 2 weeks in children or 40 mg/day > 2 weeks in adults)
• for three months after stopping immunosuppressive therapy varicella vaccine can be administered to leukaemic children in remission.

3. Postpone vaccination
• if the vaccine is suffering from an acute infection or fever (temperature > 38.5°C)

4. Be cautious if there is,
• a bleeding disorder
• a history of Guillain Barre Syndrome
• a progressive neurological disorder

5. Postpone pregnancy
• for three months after varicella vaccination
• for one month after MMR

6. Vaccination should be given in a hospital if there is history of severe allergy.

7. Vaccination should be given only in clinics where the following minimum facilities are available.
Adrenaline, Syringes, Canula, Saline and a Bed. It is preferable to have a complete emergency tray.

Dr Maxie Fernandopulle MBBS, MRCP
Consultant Paediatrician, Colombo.
SLMA guidelines information on vaccines
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The immunisation schedule in UK

The immunisation schedule in UK
The overall aim of the routine immunisation schedule is to provide protection against the following vaccine-preventable infections:

● diphtheria
● tetanus
● pertussis (whooping cough)
● Haemophilus influenzae type b (Hib)
● polio
● meningococcal serogroup C disease (MenC)
● measles
● mumps
● rubella
● pneumococcal disease (certain serotypes)
● human papillomavirus types 16 and 18 (also 6 and 11)
● rotavirus
● influenza
● shingles

The schedule for routine immunisations and instructions for how they should be administered are given in following image. The relevant chapters on each of these vaccine-preventable diseases provide detailed information about the vaccines and the immunisation programmes.

Schedule for the UK’s routine immunisations (excluding catch-up campaigns)
Schedule for the UK’s routine immunisations (excluding catch-up campaigns)

The immunisation schedule of childhood vaccinations has been designed to provide early protection against infections that are most dangerous for the very young. This is particularly important for diseases such as whooping cough, and those due to pneumococcal, Hib and meningococcal serogroup C infection. Providing subsequent immunisations and booster doses as scheduled should ensure continued protection. Further vaccinations are offered at other points throughout life to provide protection against infections before eligible individuals reach an age when they become at increased risk from certain vaccine-preventable diseases.

Recommendations for the age at which vaccines should be administered are informed by the age-specific risk for a disease, the risk of disease complications and the ability to respond to the vaccine. The schedule should therefore be followed as closely as possible.

The first dose of primary immunisations can be given from six weeks of age if required in certain circumstances e.g. travel to an endemic country. A four week interval is recommended between each of the three doses of DTaPcontaining vaccine in the primary schedule although if one of these doses is given up to a week early, either inadvertently or deliberately e.g. for travel reasons, then this can be counted as a valid dose and does not need to be repeated. However, no more than one dose should be given early in the three dose schedule. Similarly for other multiple dose schedule vaccines e.g. HPV, giving subsequent doses at a slightly shorter than recommended interval is unlikely to be highly detrimental to the overall immune response but should be avoided unless necessary to ensure rapid protection or to improve compliance. Every effort should be made to ensure that all children are immunised, even if they are older than the recommended age range; no opportunity to immunise should be missed. A notable exception is the rotavirus vaccine, where the first dose should not be given to babies older than 15 weeks of age and the second dose should not be given if the child is over 24 weeks of age. If any course of immunisation is interrupted, it should be resumed and completed as soon as possible. There is generally no need to start any course of immunisation again, as immunological memory from the priming dose(s) is likely to be maintained. Where vaccination was commenced some time previously, however, the product received may have changed and the relevant chapter should therefore be consulted.

Following immunisation all the patient’s clinical records including the GP held record and, if a child, the record on the Child Health Information System (CHIS) and the Personal Child Health Record (Red Book) should be updated with all the relevant details. When children attend for any vaccination, it is important to also check that they are up-to date for vaccines that they should have received earlier. The table below gives an example checklist at each key stage; doses of the listed vaccines that have not been received by that age should be caught up. Catch-up doses should be administered as soon as possible but leaving the appropriate intervals as advised in the relevant chapters. By these key ages, children’s immunisation status can be checked and, wherever appropriate, they should be offered catch-up vaccinations, to complete their vaccinations, as follows:

By the age of 12 months:
     Three doses of diphtheria, tetanus, polio, pertussis and Hib containing vaccines.
     Two doses of PCV conjugate vaccine.
     One dose of MenC conjugate vaccine.

By the age of 24 months:
     Three doses of diphtheria, tetanus, polio, pertussis containing vaccines.
     A single dose of Hib/MenC and PCV conjugate vaccines after the age of one.
     A single dose of MMR after the age of one.

By school entry:
     Four doses of diphtheria, tetanus, pertussis and polio containing vaccines.
     Two doses of MMR vaccine after the age of one year.
     A single dose of Hib/MenC conjugate after the age of one.

By transfer to secondary school:
     Four doses of diphtheria, tetanus, polio vaccine.
     Two doses of MMR vaccine after the age of one year.
     One dose of MenC containing conjugate vaccine since the age of one year.

Before leaving school:
     Five doses of diphtheria, tetanus, polio vaccine.
     A single dose of MenC after the age of 10 years.
     Two doses of MMR.
     Two doses of HPV vaccine (for girls only)*.

The phased introduction of the influenza vaccine began in 2013 with the inclusion of children aged two and three years in the routine programme. Eventually all children aged 2 to less than 17 years should be offered influenza vaccine annually. Chapter 19 should be consulted for age eligibility. When babies are immunised in special care units, or children and adolescents are immunised opportunistically in accident and emergency units or inpatient facilities, it is most important that a record of the immunisation is entered onto the relevant CHIS and sent to the patient’s GP for entry onto the practice-held patient record by return of an ‘unscheduled immunisation form’. Details should also be recorded in the child’s Personal Child Health Record (Red Book) in a timely manner.

Vaccination of children with unknown or incomplete immunisation status

For a variety of reasons, some children may not have been immunised or their immunisation history may be unknown. If children coming to the UK are not known to have been completely immunised, they should be assumed to be unimmunised and a full course of immunisations should be planned. Where a child born in the UK presents with an inadequate immunisation history, every effort should be made to clarify what immunisations they may have had. A child who has not completed the routine childhood programme should have the outstanding doses as described in the relevant chapters.Children coming to the UK who have a history of completing immunisation in their country of origin may not have been offered protection against all the antigens currently protected against in the UK. For country-specific information, please refer this, Document.  Children coming from developing countries, from areas of conflict or from hard-to-reach population groups may not have been fully immunised. Where there is no reliable history of previous immunisation, it should be assumed that children are unimmunised and the full UK recommendations should be followed.

Children coming to the UK may have had a fourth dose of a diphtheria/ tetanus/ pertussis-containing vaccine that is given at around 18 months in some countries. This dose should be discounted, as it may not provide continued satisfactory protection until the time of the teenage booster. The routine preschool and subsequent boosters should be given according to the UK schedule. Similarly, if a dose of MMR or a measles-containing vaccine is given before the first birthday because of travel to an endemic country, because of a local outbreak, or because it has been given abroad as part of another country’s immunisation schedule, then this dose should be discounted and two further doses given at the recommended times between 12 and 13 months of age (i.e. within a month of the first birthday) and at three years four months or soon after. An algorithm for vaccinating individuals with uncertain or incomplete immunisation status is available at Document.

Premature infants

It is important that premature infants have their immunisations at the appropriate chronological age, according to the schedule. The occurrence of apnoea following vaccination is especially increased in infants who were born very prematurely. Very premature infants (born ≤ 28 weeks of gestation) who are in hospital should have respiratory monitoring for 48-72 hrs when given their first immunisation, particularly those with a previous history of respiratory immaturity. If the child has apnoea, bradycardia or desaturations after the first immunisation, the second immunisation should also be given in hospital, with respiratory monitoring for 48-72 hrs (Pfister et al., 2004; Ohlsson et al., 2004; Schulzke et al., 2005; Pourcyrous et al., 2007; Klein et al., 2008). As the benefit of vaccination is high in this group of infants, vaccination should not be withheld or delayed.

Selective childhood immunisation programmes

There are a number of selective childhood immunisation programmes that target children at particular risk of certain diseases, such as hepatitis B, tuberculosis, influenza, meningococcal and pneumococcal infection. For more information please see the relevant chapters.

Adult immunisation programme 

Five doses of diphtheria, tetanus and polio vaccines ensure long-term protection through adulthood. Individuals who have not completed the five doses should have their remaining doses at the appropriate interval. Where there is an unclear history of vaccination, adults should be assumed to be unimmunised. A full course of diphtheria, tetanus and polio vaccine should be offered in line with advice contained in the relevant chapters. Selective vaccines against diseases including measles, mumps and rubella should be offered to young adults who have not received routine childhood immunisations. In addition, MenC should be considered in those under 25 years who are unvaccinated and for younger cohorts where the routine adolescent dose has been missed (see Chapter 22). Other vaccinations should be considered for any adult with underlying medical conditions and those at higher risk because of their lifestyle. These vaccinations include Hib, MenB, MenC, MenACWY, influenza, pneumococcal and hepatitis B. For more information please see the relevant chapters. Older adults (65 years or older) should be routinely offered a single dose of pneumococcal polysaccharide vaccine, if they have not previously received it. Annual influenza vaccination should also be offered. Adults aged 70 years should also be offered shingles vaccine.

Vaccination in pregnancy

A temporary programme for the vaccination of pregnant women against pertussis was introduced in October 2012. The purpose of the programme is to boost antibodies in these women so that they are passed from mother to baby. This should protect the infant against pertussis infection from birth until they are vaccinated at two months of age. Pregnant women should be offered dTaP/IPV vaccine in weeks 28-38 of their pregnancy (ideally in weeks 28-32), for each pregnancy. Pertussis vaccine can be given at the same time as influenza vaccine but pertussis vaccination should not be given early in order to offer the vaccines at the same time as this will compromise the passive protection to the infant. This temporary programme is described in more detail in the following documents: (Document 1, Document 2)

In 2010, routine influenza immunisation of certain clinical risk categories was extended to include pregnancy. This was based on evidence of the increased risk from influenza to the mother and because vaccination during pregnancy will provide passive immunity against influenza to infants in the first few months of life following birth. Protection of the mother should also reduce the risk of her transmitting infection to a newborn baby. Inactivated influenza vaccine should therefore be offered to pregnant women at any stage of pregnancy (first, second or third trimesters), ideally before influenza viruses start to circulate. Influenza vaccination is usually carried out between October and January, however clinical judgement should be used to assess whether a pregnant woman should be vaccinated after this period, taking into account factors including the level and severity of influenza-like illness in the community and the availability of inactivated influenza vaccine. Influenza vaccine can be given at the same time as pertussis vaccine but influenza vaccination should not be delayed in order to offer the vaccines at the same time. Inactivated influenza vaccines are preferred to live attenuated vaccines for pregnant women.

References -

Klein NP, Massolo ML, Greene J et al. (2008) Risk factors for developing apnea after immunization in the neonatal intensive care unit. Pediatrics 121(3): 463-9.
Miller E, Andrews N, Waight P et al. (2011). Safety and immunogenicity of coadministering a combined meningococcal serogroup C and Haemophilus influenzae type b conjugate vaccine with 7-valent pneumococcal conjugate vaccine and measles, mumps, and rubella vaccine at 12 months of age. Clin Vaccine Immunol 18(3): 367-72.
Ohlsson A and Lacy JB (2004) Intravenous immunoglobulin for preventing infection in preterm and/or low-birth-weight infants. Cochrane Database Syst Rev (1): CD000361. Pfister RE, Aeschbach V, Niksic-Stuber V et al. (2004) Safety of DTaP-based combined immunization in very-low-birth-weight premature infants: frequent but mostly benign cardiorespiratory events. J Pediatr 145(1): 58-66.
Pourcyrous M, Korones SB, Arheart KL et al. (2007) Primary immunization of premature infants with gestational age protein responses associated with administration of single and multiple separate vaccines simultaneously. J Pediatr 151(2): 167-72.

Schulzke S, Heininger U, Lucking-Famira M et al. (2005) Apnoea and bradycardia in preterm infants following immunisation with pentavalent or hexavalent vaccines. Eur J Pediatr 164(7): 432-5.
Original Article Source - www.gov.uk
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National Immunization Programme of Sri Lanka and Key Principles in Immunization

National Immunization Programme of Sri Lanka and Key Principles in Immunization
National Immunization Programme of Sri Lanka
In the year 1798, Edward Jenner first demonstrated that vaccination offered protection against smallpox. He used cowpox (poxvirus bovis) for the immunization of man against the smallpox virus (poxvirus varialae). For the last 200 years, the use of vaccines has continued to reduce the burden of many bacterial and viral diseases.

Smallpox itself has been eradicated, and poliomyelitis in the verge of eradication. In Sri Lanka, the last case of virologically confirmed poliomyelitis patient was reported in 1993.

In Sri Lanka, the introduction of routine immunization has generally reduced the incidence of several vaccine preventable diseases. Similar success in disease reduction has been demonstrated by immunization programmes in many other countries. The World Health Organization’s (WHO) Expanded Programme on Immunization (EPI), with assistance from the United Nation’s Children’s Fund (UNICEF) and other donors, has made great strides in extending these benefits to developing countries. Immunizations permitted the global eradication of smallpox, and may do the same for poliomyelitis and some other diseases.

Immunizing a child not only protects that child but also other children by increasing the general level of immunity and minimising the spread of infection.

History of Immunization in Sri Lanka


The history of immunization in Sri Lanka goes back to the 19th century. The law relating to compulsory vaccination (against smallpox) is referred to in the Vaccination Ordinance of 1886.
The Expanded Programme on Immunization (EPI) established in 1978, has continued to make excellent progress over the past two decades, most notably in terms of achieving high immunization coverage and disease control. The milestones of immunization in Sri Lanka are given below.

1886 - Vaccination against smallpox introduced under the Vaccination Ordinance
1949 - BCG Vaccination introduced against tuberculosis
1961 - “Triple” vaccination introduced against diphtheria, whooping cough and tetanus
1962 - Oral polio vaccine introduced
1963 - BCG vaccination of newborn introduced
1969 - Tetanus Toxoid administration to pregnant mothers introduced
1978 - Launching of the Expanded Programme on Immunization
1984 - Measles vaccination introduced
1991 - Revision of Tetanus Toxoid schedule
1995 - First National Immunization Days conducted.
1996 - Introduction of Rubella vaccine
2001 - Introduction of revised National Immunization Schedule with MR and ATd
2003 - Introduction of Hepatitis B Vaccine on phase basis
2008 - Introduction of Hib containing Pentavalent vaccine

Immunization Schedule


With the commencement of the EPI Programme in 1978 focus was to control childhood T.B., tetanus, whooping cough, diphtheria, polio and neo-natal tetanus. In 1988, the focus shifted to disease elimination. In 1991, a fifth dose of OPV was introduced at school entry to facilitate the polio eradication process. Rubella, Hepatitis B and Hib containing Pentavalent vaccines introduced to the programme gradually over the years. The present EPI vaccination schedule is given in annex below. JE vaccine was introduced to high-risk areas in 1987. Primary Immunization against JE consists of 3 doses at an interval of 2 – 4 weeks between the first and second doses and one year between the second and third. A booster dose is given every 4 years after the primary immunization. JE immunization is offered children below the age of ten years living in identified high-risk areas.

Principles for Determination of Immunization Schedule

  • Age specific risk of disease
  • Age specific immunological response to vaccines
  • Potential interference with the immune response by passively transferred material antibody
  • Age specific risk of vaccine associated complications
  • Programmatic feasibility
  • In general vaccines should be administered to the youngest age group at riks for developing the disease

 Objectives of the National Immunization Programme

  • Eradication of poliomyelitis  Elimination of neonatal tetanus, diphtheria, measles and rubella
  • Reduction of morbidity and mortality due to whooping cough prevention of outbreaks
  • Reduction of morbidity and mortality due to hepatitis B
  • Reduction of morbidity and mortality due to Japanese Encephalitis
  • Reduction of morbidity and mortality due to Haemophilias influence B disease

To achieve the above objectives, immunity has to be create in population against the specific organisms causing above diseases by administering potent vaccines in correct dosage using correct technique and according to the national immunization schedule.

‘Immunity’ is a term that originally implied exemption from military service or taxes; it was introduced into medicine to refer to those people who did not get further attacks of smallpox or plague once they had had the disease. In a wide sense the term refers to the resistance of a host organism to invasive pathogens or their toxic products. Immunity is divided into two main types

Non-specific immunity (sometimes called ‘innate immunity’):
which includes the general protective reaction of the organism against invasion.

Specific immunity: Immunity is the ability of the body to tolerate material that is indigenous to it and eliminate material that is foreign. The immune system is comprised of organs and specialized cells that protect the body by identifying harmful substances, known as antigens, and by destroying them by using antibodies and other specialized substances and cells. There are two basic ways to acquire this protection – active immunity and passive immunity.

Passive immunity: involves either the transfer of antibodies or in some diseases, of sensitised white blood cells, from an immune to a non-immune person. Natural passive immunity is transferred from mother to child across the placenta (and in the colostrum in subhuman primate species). Artificial transfer is the therapeutic use of various antitoxins or gammaglobulins, as in the treatment of tetanus, diphtheria, gas gangrene, snakebite, and immunodeficiency states. The passive immunity is short-lived, depending on the life-span of the antibody or the transferred cells in the recipient. Once they disappear, the host is again susceptible to the disease.

Active immunity: is provided by a person’s own immune system. This type of immunity can come from exposure to a disease or from vaccination. Active immunity usually lasts for many years and often is permanent. Live microorganisms or antigens bring about the most effective immune responses, but an antigen does not need to be alive for the body to respond.

Types of Vaccine


Live attenuated vaccines are derived from disease-causing viruses or bacteria that have been weakened under laboratory conditions. They will grow in a vaccinated individual, but because they are weak, they will cause either no disease or only a mild form. Usually, only one dose of this type of vaccine provides life-long immunity, with the exception of oral polio vaccine, which requires multiple doses.

Inactivated vaccines are produced by growing viruses or bacteria and then inactivating them with heat or chemicals. Because they are not alive, they cannot grow in a vaccinated individual and therefore cannot cause the disease. They are not as effective as live vaccines, and multiple doses are required for full protection. Booster doses are needed to maintain immunity because protection by these vaccines diminishes over time.

Inactivated vaccines may be whole-cell or fractional. Whole-cell vaccines are made of an entire bacterial or viral cell. Fractional vaccines, composed of only part of a cell, are either protein- or polysaccharide-based. Polysaccharide-based vaccines are composed of long chains of sugar molecules taken from the surface capsule of the bacteria. Unless coupled with a protein, pure polysaccharide vaccines are generally not effective in children under the age of two years. This coupling process is known as “conjugation.” Recombinant vaccines are produced by inserting genetic material from a disease-causing organism into a harmless cell, which replicates the proteins of the disease-causing organism. The proteins are then purified and used as vaccine.

Types of Vaccine,

• Live attenuated
– Virus, e.g., oral polio vaccine (OPV), measles, yellow fever
– Bacteria, e.g., BCG

• Inactivated

Whole
– Virus, e.g., inactivated polio vaccine (IPV)
– Bacteria, e.g., whole-cell pertussis

Fractional
– Protein-based
– Subunit, e.g., acellular pertussis
– Toxoid, e.g., diphtheria and tetanus
– Polysaccharide-based
– Pure, e.g. meningococcal
– Conjugate, e.g., Haemophilus influenzae type b (Hib)


• Recombinant, 
-Hepatitis B


Impact of Immunization on Disease Transmission

An infectious disease is an illness that occurs when an infectious agent is transmitted from an infected person, animal, or reservoir to a susceptible host. Some of the factors that influence transmission include:

A basic concept of public health is that every individual who is protected from a disease as a result of an immunization is one less individual capable of transmitting the disease to others. Individuals who have been immunized serve as a protective barrier for other individuals who have not been immunized, provided that the number immunized has reached a certain level. Reaching and maintaining that level, which varies by communicable disease, provides “herd immunity” to unimmunized individuals. The figure bellow illustrates the concept of herd immunity. It shows two hypothetical populations in which each individual comes in contact with four other members of the population. Both populations have been exposed to a hypothetical disease that is 100% contagious. The first group has no immunity to the disease and, therefore, the disease spreads to everyone. The second population is partially immune due to vaccination services that have protected 75% of the population. Even though only 75% are immune because of vaccination, the disease does not spread to all of the remaining 25% of susceptible individuals. This is because some of the remaining susceptible are protected by the fact that they do not come in contact with an infected individual. This is how herd immunity can protect more people than those who actually receive vaccinations and thus inhibit the spread of disease.

Note that if the susceptible individuals are unevenly distributed, e.g., if they cluster in urban slums, the level of protection in that population will need to be higher to prevent transmission. However, immunization coverage is not near 100 % these unimmune persons (susceptible) can accumulate over the years and can cause outbreaks as experienced in 1999 measles outbreak. Therefore, it is important to plan and organize our immunization programme in such a way that minimum susceptible accumulate over the years.
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7 Secrets Of Permanent Fat Loss And Fitness - Lean, Strong and Sexy body awaits (Full article)

7 Secrets Of Permanent Fat Loss And Fitness - Lean, Strong and Sexy body awaits (Full article)
The Fat Loss Fast System - image
What kind of benefits am I specifically talking about?

• No longer will you have to be a slave to the gym, spending countless monotonous hours each week on a treadmill, elliptical machine, or something similar.

• No longer will you have to rush to be on time for an aerobics class. No longer will you have to be in the gym for 4, 5, or 6 days per week, performing various different forms of exercise to get all of the benefits you seek.

• No longer will you have to follow some wacky fad or crash diet plan calling for the elimination or severe reduction of crabs or something similar.

• No longer will you have to maniacally watch your diet every second of the day, wondering if that cookie you had will require another 45 minute aerobic session. 


• No longer will you have to feel bad about yourself for not being able to live up to all of these popular recommendations and more.

• And most importantly, no longer will you be a slave to the multimillion dollar fitness industry that is keeping you from reaching your goals. Imagine having the confidence in knowing that the little time and effort you respending each week is creating a healthy environment inside your body that is simultaneously burning fat and building muscle, strength, and endurance 24 hours a day, seven days a week.


Imagine knowing that you must eat carbohydrates every day as a major part of your food intake, and not having to worry about it all going to your belly, hips, or thighs.

Imagine knowing that you’re greatly reducing your risk of disease and other physical and health problems as you age, and looking and feeling years younger than you actually are.

Imagine impressing almost everyone you know with your new body and self confidence, how that will transfer over to more success in all other aspects of your life, and how everyone will want to know your secrets.

And imagine having the extra time to enjoy your hobbies and interests, and what really matters in life…your family and closest friends. Now stop imagining, because this really is all within your grasp…and it all starts with the principles I reveal in this manuscript. So get excited…the best is within you!

Secret #1 - Create A Lifestyle Change With Systems

The 1st secret to permanent fat loss and fitness is: create a lifestyle change with systems. Now, what am I talking about here…well, for starters, if you’re not thinking in terms of a lifestyle change, you’re in trouble. If you’re idea of fitness is going on a diet for a little while and taking a few aerobics classes, you’re not going to succeed. Period. If you want to live your life in your own lean, healthy, and strong body, you need to take the steps necessary to literally change your lifestyle.

Now, a lot of people have heard this before, but it’s not the fact that you have to make it a lifestyle that’s the secret…the secret part of it is how to do this effectively. And that starts with something most people completely miss: identifying what your lifestyle is today.

The first step is to think about your eating and exercise habits as they are now and WRITE THEM DOWN on a piece of paper. What do you eat on a typical day and throughout the week? How much are you eating? How often are you working out? What kind of workouts are you doing?

You also need to examine your stress level and what are primary forces behind your stress. You also should take a look at your rest and sleep schedule. And lastly take a look at your mindset and your thoughts on how you see yourself and your lifestyle. These questions and topics will give you a snapshot of your current lifestyle…all on 1 sheet of paper for you to see and review.

After spending a few minutes jotting this data down and reviewing it once or twice, you can probably start to see just how big this whole fat loss and fitness thing really is, and why making a small temporary change here or there (as most diets or exercise plans give you) might win a battle or two, but not the WAR you’re fighting.

There are just too many variables to try and control by using the bandage approach. And what I mean by that is, most people try to fix their health and fitness problem like someone would fix a cut or scrape with a band-aid. Your health and fitness is not a simple cut or a scrape, and it needs more than a temporary fix. So a lifestyle change is what is needed for a long term solution to fat loss and fitness. That is essential.

Now, once you’ve established a snapshot of your current lifestyle, you need to move on to the second step…changing your lifestyle through systems. Here’s what I mean by that:

Ask any successful business person what is at the heart of his or her success and most of them will mention a system of some type. If you have a proven and successful system, you will be successful at whatever you’re trying to accomplish. If you don’t, you’ll be lost. I spent years of my own life searching the fitness wasteland for methods that I could use to burn fat, build muscle, and get healthy with little time commitment. At some point I realized that I was creating my own system for fitness success.

Once I realized that, I was able to recommend this same system to my friends and family members interested in lifelong health and fitness. And guess what, it worked for those who applied. It was a proven and successful system. All I did was apply it to another person. Just like in business, if you have a successful and proven system, you can essentially apply the system over and over again to create new businesses. They’re all based on the same successful and proven model or system.

Again, without a system, you may get to find what you’re looking for, but it could take years or more, and a lot of frustration to be sure…I’m sure if you think back to a time in your life when you were investigating a particular topic or discipline, you’ll realize you spent a lot of time and effort in doing so.

If you had a system on how to find those answers, it would have been a lot easier and more successful. You would have made far fewer errors and saved yourself a load of time.

As I said earlier, I didn’t have a system early on in my fat loss struggles, and as a result I was trying to plug the holes in my lifestyle with diets, miracle pills, and exercise gizmos.

So analyze your current lifestyle (be brutally honest), decide what needs to change and then get to work on getting a proven and successful system that will create a new lifestyle for you. ..one that you can lead for the rest of your lean and healthy life.

Secret #2 - Exercise Less, But With More Intensity

The 2nd secret to permanent fat loss and fitness is: Exercise less, but with more intensity. Now, not many people have probably told you to exercise less, right? Well, what I’m getting at here is that most people are exercising far too much, but with not enough intensity.

You see, while some of the top minds in fitness are starting to realize that intensity is the fastest ticket to fat loss and lifelong health and fitness, most are still recommending long, boring cardio workouts as the primary form of exercise for burning fat. And this is really sad because while this type of exercise certainly can burn fat, it is far from the most effective of methods available.

There are a few reasons for this, but mainly it has to do with the fact that this type of exercise primarily burns fat while you’re exercising…while this may sound good at first, it’s actually bad news. This can cause your body to start saving a reserve amount of fat to have available for your next long cardio session. You see, when you exercise like this exclusively, your body wants to hold on to your fat just so it can be burned during the next time you exercise. So if you want to burn more fat, you’ll have to do more and more of it.

Even if this type of exercise worked really well, anyone who has experienced week after week of hour long cardio sessions done 4 or more times per week knows that this is far from exciting or enjoyable.

Yeah, there are exercise addicts out there who like spending their whole week in the gym, but I know most do not. The fact of the matter is that there are more rewarding things in life like spending time with our families, so my goal has always been to find the most efficient route to health and fitness.

So, the way we get the results we want is by increasing our intensity. Intensity is the name of the game in productive results-producing exercise. It’s just the way the body responds to a stimulus. The greater the stimulus, the greater the response from the body, provided you give it time to rest and recover.

The basic principle here is, you can work hard, or you can work long, but you can’t do both effectively. If you’re working hard enough, you literally won’t be able to work very long or often…you’ll be challenging your body to improve, and you’ll need to extra rest to extract maximum benefit from your exercise. It is a simple concept but the #1 reason why people’s exercise programs fail them. They are giving their body NO REASON to change or improve when attempting something they’re already capable of.

And when you are working with sufficient intensity, your body switches to primarily burning calories from the carbohydrates in your muscles instead of body fat. And after your intensity based workout is over, you body then begins to burn existing body fat and calories to fuel the growth and repair processes that occurs (which is a massive combination of complex chemical reactions). The best part is, you body can continue to burn body fat like this for up to 48 hours after this workout is over! Now you’re working smart instead of long.

Now if we simply applied this intensity principle to aerobic workouts, we instantly make our exercise more effective. But even when doing this, I still found the results not to be up to my expectations. Why?

Because I also had to engage in resistance training or weight training on top of this to build fat burning muscle mass and develop a stronger body. Having to perform two different forms of exercise each week still kept me in the gym for at least an hour 4 or more times per week. Better, but I wanted it to be even easier and less time consuming.

Now, you may already know that adding lean muscle mass to your body is one of the big secrets to burning fat all day long, even when you’re not working out. The reasons for this are two-fold:

First, a pound of lean muscle requires about 40-50 calories per day to keep alive, and when you add several pounds of muscle, you can create a calorie deficit in your body which melts off even more fat. On top of that, the growth and repair process mentioned above that occurs after intense strength training can burn huge amounts of calories and body fat for up to two days later.

And the health benefits are tremendous…properly applied resistance training can increase your heart and lung’s capacity for work, with helps reduce risk of cardiovascular disease.

A Big Discovery In Faster Fat Loss

The big secret I’ve found is that combining high intensity cardio with high intensity strength training into one workout is the absolute fastest way to burning fat, building muscle, strength and endurance…all at the same time. It awakens and unlocks the fat burning furnace inside of your body 24 hours a day, 7 days a week.

It must be performed correctly however, not like you see the typical person using weight training…but when performed correctly as I teach readers of my articles, this type of exercise will outperform anything else I’ve seen, and will only take an average of 20 minutes per session, and only needs to be performed twice or three times per week.

Perhaps the best part is, as you progress, you’ll have to perform even less exercise…that’s right, even less exercise (this is an amazing but true fact of how the body’s ability to tolerate intense exercise actually decrease the stronger and leaner you get.)

To experience the benefits for yourself, let’s take the Squat exercise as an example. The Squat is one of the top 2 exercises for burning fat and building a strong and shapely body. But sadly most people spend too much time with the exercise but not nearly enough intensity. Here’s how to change that: Instead of performing a set or two of warm ups followed by 3-5 “work sets” as most people would do, try this. Cut the amount of weight you use in half. SLOW the movement down to about 5-10 seconds per repetition (concentrate on a slow lifting, pausing at the top, and a slower lowering of the weight), right from the very first one. Keep doing this until you cannot complete another repetition in at this speed despite your greatest, and I mean greatest effort.

Now, 99% of people working out today have never experienced what you will experience after performing only 1 set of the Squat exercise in this fashion. If you did this right, your heart will be racing…your lungs gasping for air…your thighs, butt, hips, and calves will feel like jello. And it probably took you only about 60 seconds to stimulate your body this way.

You can even try this without any equipment and just do a body weight Squat. You’ll want to slow this down even further, depending on your strength level in the movement, but you’ll still feel the amazing difference.

This is a window into the kind of exercise that I and my students have been using to simultaneously burn stubborn body fat, build strong sexy muscle, strength, and endurance, all in just minutes per week. And it can keep the fat off permanently. Compared to what’s typically recommended these days, it’s almost magical.

Secret #3 - Focus On The Right Foods, Nutrient Rich

The 3rd secret to permanent fat loss and fitness is: focus on the right foods, nutrient rich. We’ve all seen the fad diet books and plans out there that promise all sorts of fabulous weight loss with very little effort. What we typically find out though, after going on one of these diets, is that they’re unusual. They require you follow a very unusual way of eating compared to what common sense and Mother Nature would tell you.

We also find out that once we go off of these diets we gain the weight back faster than we lost it, and usually add a few more pounds on top of it (often due to loss of muscle mass in the process). This is obviously not the way to go, yet so many people are still duped into following these wacky diets…again and again and again.

The big secret I’ve found in eating is that instead of focusing on what you can’t eat or what you shouldn’t eat, we should be concentrating on the types of foods that create an ideal environment for satisfying hunger. This is true because when it comes down to it, we have to create a calorie deficit if we want to lose fat.

That is, we have to burn more calories than we consume. The exercise principles I described in secret #2 will help to create a deficit without changing your eating habits at all. But if you want fast success, and lasting success, you must employ proper eating strategies as well.

The Big Issue: Too Many Calories

Whether you like it or not, the big problem people have is simply eating too many calories…there is too much going in and the only place the excess is going is to your fat stores. So what I’ve found is that instead of restricting yourself of entire food groups (like carbohydrates), it’s far easier and better from a fat loss and health standpoint to concentrate on eating foods loaded in nutrients. Why? Because our hunger is driven by nutrient consumption. Not just the macro nutrients (protein, crabs, fats), but even more so by the micro nutrients. The vitamins, minerals, etc. that are found in certain foods and not so much in others. In fact most people don’t even think about this, instead focusing on how many crabs or how much fat or protein they eat.

And the mainstream diets are this way too. When you analyze it, most diets are just variations of either low calorie, low fat, or low crab. They’re all focused on the macro nutrients with little regard for choosing food based on the micro nutrients. which really satisfy your body and your hunger.

When you focus on these foods, many of the details take care of themselves. Think about it, these are the foods your body craves naturally. why? Because they’re loaded with nutrients. your body craves nutrients. I’m talking about unrefined whole grains, beans, legumes, vegetables, fruits, nuts and seeds. If you give your body what it craves, it’s very unlikely you’ll have overeating problems. Period.

This one fact could save so many people from so many health problems it’s not even funny. And most issues with fat gain simply disappear when eating this way even 80-90% of the time. And on top of this, you’re automatically lowering your chance for various diseases and ailments that plague the person on the typical over sized and protein heavy American or western diet.

Now, focusing on nutrient rich foods is the foundation, but there are other factors we can manipulate to get the desired fat burning effect while supporting the muscle growth we are stimulating with our proper exercise application as I talked about in the last secret. These include eating smaller meals more frequently, managing your calorie intake without actually counting calories, and more. Perhaps just as important as what foods you are eating is what you are drinking. The habit of drinking loads of water each day should be one you want to develop right now. While water is essential for almost every bodily process we go through, it is absolutely vital to fat burning. If you don’t get your water, you can forget about maximum fat burning.

The reason for this has to do with what happens to your body when it is dehydrated. It basically stores fat at an accelerated rate, and the sooner you get hydrated, to sooner your body will be able to metabolize your body fat stores for energy.

So make sure you’re eating foods that are rich in nutrients and make sure you’re getting more than your fair share of water. Give the body what it craves…and it will reward you.

Secret #4 - Know The Numbers

The 4th secret to permanent fat loss and fitness is: know the numbers. If you don’t know the numbers, you have little chance of success in fat loss and fitness. Let me explain. Just like anything else in life, if you’re not tracking what works and what doesn’t work, you’ll be using a shotgun approach that will take much longer and not work as well as an approach that includes tracking. This is especially important in relation to your exercise and fat loss and fitness progress. Let’s look at the business world again for a moment. In any business, at the end of the day, results are measured by revenue, or the money that was made. If the business owner doesn’t know the numbers, they won’t know if they’ve made any money. And thus they have no business. Pretty simple, but the most powerful metric a business owner can track.

I’m a big NBA basketball fan, but do you think I’d enjoy watching my favorite team if they didn’t keep score? Of course not! If they don’t keep score, we don’t know who’s winning, and thus there is no “game” to win or lose. They have to know their numbers to know who wins and who loses.

Again, strikingly simple, but the fact is that most people don’t track their exercise routines at all. How do they know if they’re winning or losing the fat loss game? In fat loss and fitness it’s all about progression. When using a progressive based form of exercise like properly conducted intense resistance training, your fat loss and muscle, strength, and endurance gain is mirrored by how much stronger you’re getting each workout. And as such, you should base your progress primarily by monitoring your strength gains from workout to workout.

If you don’t know if you’re getting stronger, or how much stronger, you’ll have a tough time advancing through the workouts and creating that fat burning environment inside of your body.
This is because the speed of your progress is related to a combination of the intensity you’re using, along with the volume and frequency of your exercise. By monitoring your progress with a particular combination of these variables, you’ll be able to adjust if necessary for optimal results.

Next, you’ll want track your body fat percentage. Forget about what the scale says or what your “ideal weight” should be. Forget about Body Mass Index charts. These are all measures of weight loss, not FAT LOSS. We don’t want to lose weight, we want to lose fat.

It should then become obvious that tracking the percentage of our bodies that is fat, and watching that number drop, is the other key factor in determining our wins or losses in the fat loss game.
So you see, recording your progress is key to getting that lean and fit body you desire and everyone else envies…and if you’re not doing it, you’re using the shotgun approach: just spraying bullets and hoping you hit something. And this always results in the wasting of your most valuable asset…your time.

By doing this you’ll not only be able to watch the inches melt off, but you’ll also be able to use these records as a motivational tool, spurring you on to even further progress…and even inspiring others you care about to do the same. So, bottom line, make sure to keep accurate records of your workouts and your progress. Just like in any business or in sports, you won’t know if you’re winning if you don’t keep score.

Secret #5 - Surround Yourself With Positive People

The 5th secret to permanent fat loss and fitness is: surround yourself with positive people. Ok this one is extremely important. Surround yourself with positive people. I can’t stress this enough…and this might hurt your feelings a bit, but your friends and family may be making you fat.

Think about that for a minute. Your mindset, whether you like it or not, is shaped (and often times greatly so) by your outside influencers, the people you choose to associate with, namely your friends and family.

If you’ve got a host of people telling you that you’ll never succeed at your fitness goals, you’ll have a tougher time. Even if you have developed extraordinary mental toughness, the slightest hint of doubt can cloud your mind and let loose all sorts of nasty negative thoughts. And don’t think that these people will be obvious to spot either.

I don’t mean to scare you, but you’ve probably got all sorts of negative people around you right now. Spotting them isn’t always easy, so here are a few of the types of naysayers that I’m talking about:

The Grinch

The Grinch is transparently obvious. They’re the ones that will laugh at your goals and tell you to your face that you’ll never achieve them. These people are usually this way because their own goals have been crushed in the past, don’t know how to get past this, and have just given up on them at this point. They’ve decided to be miserable and you won’t be changing their minds anytime soon.

The Model

Then you’ve got these people that have a superiority complex. I call these the Models. Models find achieving their fitness goals relatively easy, mostly due to genetic or situational factors, and similar to the outright negative people, will laugh off your aspirations. They won’t take you seriously and are more concerned with themselves then supporting your goals too.

The Baby

You’ve also got those that have given up, are fat and out of shape, would rather feel sorry for themselves and want you to be that way too. I call these people the Babies. Babies don’t want you to succeed with your plans because they’ve had somany past failures in their own fat loss goals that they’ve given up. So many times they sabotage your plans, whether they do so knowingly or just by behaving as they normally would. This is basically an unhealthy negative and needy person sucking you into their lifestyle so they have some company.

So there you have it…The Grinch, The Model & The Baby. Now you know who to watch out for. OK, just as I asked you to evaluate your current lifestyle earlier go ahead and take a look at the people you spend most of your time with. WRITE THEIR NAMES DOWN on one piece of paper. Are they helping or hurting your efforts for life long fitness and health? Why? If they’re not helping, go ahead and have a discussion with them. Let them know you’re serious about changing for the better and that you don’t have time for negative influences or people anymore. And if they don’t budge, stop associating with them, or greatly reduce your contact.

Now I realize you may have some longstanding relationships with these types of people, and this is not an easy thing to do in some cases. But it’s a choice you should really consider making if you’re serious about living your life in the healthy and lean body you want to.

Where do you want to be in 5 years? Would you rather be in a new lean, strong, and sexy body or still deciding whether or not to rid yourself of communicating with people who are holding you down. You must MAKE A DECISION, or you will be in exactly the same shape (or worse) as you are today.
This reminds me of my favorite quote of all time: If you think you can’t, you can’t, and you won’t. If you think you can, you can, and you will. It’s that simple. If others around you think you can’t, they’ll let you know one way or another, and then it is up to you to shield yourself from this. Or, you can just work on surrounding yourself with positive people, thereby making it much easier on yourself.

Secret #6 - Get A Coach Or A Mentor

The 6th secret to permanent fat loss and fitness is: Get a coach or a mentor. Now I know what you’re thinking…”I don’t need a coach or mentor, I can do it by myself”. While that may be true, as I did it myself for the most part, it is always easier and faster when someone shows you the way. I like to compare this with the process of traveling a long distance. Let me explain.

If you wanted to go from New York City to Los Angeles by car, you wouldn’t just get in the car and start driving would you? In essence, that is what many people are doing in their quest for fitness. They are just getting in the car and driving, with a goal in mind, but not much idea on how to get there.

Now, some people go ahead and actually grab a map and follow that. This will certainly help you get there, giving you various roads and avenues to take. But you’ll probably run into a few dead ends along the way. And the journey will take longer than you’d probably like. But what if someone came to you with detailed instructions on the exact roads to take and what traffic or construction delays to avoid. You most certainly would get there sooner and with less effort.

Finding the right coach or mentor in your quest for permanent fat loss and fitness can be like getting a “Google Maps” to your dream body. And before you go ahead and think you don’t need one of these people in your life, did you know that world champion golfer Tiger Woods has a coach?

The man with the greatest golf swing in the world and on his way to being the greatest golfer in history (if not already) relies on a coach to help him. And surprise surprise, most every successful or famous person has had a mentor or coach at one time or still uses them today. You think Oprah, arguably the most successful business woman in the last 100 years, does it all by herself. What about Warren Buffet, Donald Trump, etc.? All of these people got help and continue to get help to stay at the top of their game.

So think about it, if Tiger Woods and other super successful people need a coach or coaches to excel and reach their goals, shouldn’t you consider having one too? I didn’t invent the principles I teach in my articles without first studying under some mentors that laid the groundwork before me.

The great news is that it should be a lot easier achieving your life long fat loss and fitness goals then becoming the world’s greatest golfer, so just imagine how much positive impact a coach can bring to you.

Now, this coach or mentor could be a personal trainer who is also emotionally supportive, or it could be a combination of a friend, a relative, or motivational expert. It could also even be someone who supplies you with that system for success like mentioned earlier. Whoever it is, make sure they are accessible to you and will be there to offer the support and encouragement you need. And don’t look for what I call a “softy”. A softy is someone who is too comfortable with you and will let you off easy. These people make terrible coaches. You need some one who can be supportive, but is also there to keep you in line and give you a kick in the pants ever so often if you need it.

There’s no substitute for experience, so you’ll also want to make sure your coach or mentor has been there and done that…not one of these talking heads that has no real experience. You want someone that has either gone through what you’re going through or helped others in similar situations.

You can’t do it alone…at least not as quick or as easy. So go ahead and get yourself a coach…a mentor that you can look to for guidance, support, and encouragement (and that periodic kick in the pants) as you move through to getting the lean, strong, and healthy lifestyle you deserve.

Secret #7 - Be A Doer, Not A Talker (Or A Know It All)

The 7th secret to permanent fat loss and fitness is: Be a doer, not a talker or know it all. The way I see it, there are two kinds of people in this world. You’ve got your talkers, or what I call know it alls. And on the other side of the fence you have your doers. Let’s talk about know it alls first.

I’m going to go ahead and say that most people fall into the talker and know it all group. If you think about the people you know, you’ll probably notice the same thing I have. Most people are not proactive. Most people are reactive. And when it comes to fat loss, fitness or any other subject or discipline, you’ll find loads of people who talk a good game, but do not practice what they preach, because they are not doers.

And the minute you start giving them some advice, they’re quick to stop you to tell you that they know all about what you’re telling them, because they know it all. But wait a minute, why aren’t they doing what they apparently already know and are aware of?

Talkers will also come up with all kinds of excuses as to why they didn’t do something, or why something didn’t work for them. They’ll also tell you why something isn’t going to work for you, because they know it won’t work for them because they just won’t do it!

Now, I know not everybody is not 100% one way or the other on this, and you might be a doer most of the time, but the talker in you likes to take over whenever faced with what seems like a daunting task like burning stubborn body fat. So it all starts with identifying who you are. Take a look at your past and how you naturally responded to various challenges. Think back at how those situations turned out. Did they happen the way you would have liked them to happen? Now, for the ones that didn’t, do you think being more of a doer and shutting down that talker side of your personality would have resulted in a more positive outcome?

Chances are, yes, it would have. Eliminating the talker side of your persona is not always easy…it takes practice and repetition. But being aware of it and being able to identify it when it happens is key, because when it happens…when that talker comes out, you can make the conscious decision to squash that talker and turn on the doer inside.

If you want to get the kind of success in fat loss and fitness that you’ve been seeking, you must become a doer. I cannot stress this enough, because doers are winners…they achieve goals and the things they want…talkers and know it alls are almost always on the losing end. I know where you would rather be. So make up your mind and get going! Be a doer, not a talker.

Bonus Secret (#8) - Invest In Your Health Now, Don’t Pay For It Later

The bonus secret to permanent fat loss and fitness is: Invest in your health now, don’t pay for it later. Yet another roadblock on the path to life long health and fitness relates to what you’re willing to invest now versus what you’ll pay for later. And it’s a tricky situation for a lot of people because you don’t really see what the costs of poor health are when you’re younger.

It’s always easier to say, well it’s not going to happen to me, or some people just ignore it all together. So they put off making that investment in their health now. But they forget that they’re going to pay for it later, and then some. And I’ve even talked to people who are afraid to spend a couple hundred bucks to improve their health.

These people just don’t get it, and don’t understand the true value of having a lean body at all. They fall into that “talkers” category I mentioned earlier. They probably won’t end up reaching their goals.
Now, besides the fact that investing in your health provides the cosmetic benefits of a lean, strong, and sexy appearance, you’re also setting yourself up for reduced risk of various diseases and medical conditions that have the potential to literally cost you thousands upon thousands of dollars or more depending on your health insurance situation at that time.

Not to mention spending your time to and from the doctor’s office or hospital. And paying for medical costs when you’re older is not what most people are looking forward to as they age. That certainly doesn’t sound like fun to me. So take care of yourself now, while you can create a real difference in your health risks, and do all that you can to prevent unexpected ailments in the future. Invest in your health…don’t pay for it later.

What’s Next?

Alright, so that’s it…your 7 secrets to permanent fat loss and fitness, well 8 actually. Let’s review them once more:

1. Create A Lifestyle Change With Systems

2. Exercise Less, But With More Intensity

3. Focus On The Right Foods, Nutrient Rich

4. Know The Numbers

5. Surround Yourself With Positive People

6. Get A Coach Or Mentor

7. Be A Doer, Not A Talker (Or Know It All)

8. Invest In Your Health Now, Don’t Pay For It Later


So there you have it, 8 powerful secrets that you can use to succeed with your fitness goals right now. The next step is for you to find a way to apply and expand on these secrets in your own life…

…And if you’re serious about life long fat loss and fitness, I put together a special offer just for you to give you the jump start that you need to really super charge your success, the right way.

Or, if you’re already making progress with your goals, my offer will give you the exact techniques and secrets I and my readers and students use. They’ll really give you a huge edge over almost everyone else in the pursuit a lean, strong, and healthy body.
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