Disease dilemmas. Flashcards
(114 cards)
1
Q
List the ways in which diseases are classified
A
- Infectious
- Non-infectious
- Communicable
- Non-communicable
- Contagious
- Non-contagious
- Endemic
- Epidemic
- Pandemic
2
Q
Define ‘infectious’
A
- Diseases caused by organisms - such as bacteria, fungi, protoctista and viruses, passed directly or indirectly from person to person
3
Q
Define ‘non-infectious’
A
- Diseases NOT caused by pathogens: these include - lifestyle factors, environmental toxins or gene mutation.
4
Q
What is an example of an infectious disease that is non-contagious?
A
Malaria
5
Q
Define ‘communicable disease’
A
- Diseases carried by micro-organisms that are transmitted through people, animals, surfaces, food or air.
6
Q
Define ‘contagious disease’
A
- Diseases that are passed directly from person to person through close proximity or physical contact.
7
Q
What is a zoonotic disease?
A
Infectious diseases such as plague and rabies - transmitted from animals to humans.
8
Q
What % of diseases originate from animals (zoonotically)
A
- 60%
9
Q
Define endemic
A
- A disease that exists permanently within a geographical area or human group
10
Q
Define epidemic
A
- A disease outbreak that spreads quickly through a usually restricted geographical area.
11
Q
Define pandemic
A
- An epidemic that spreads worldwide
12
Q
What are 3 OVERVIEW factors to consider in the spread of disease?
A
- Social
- Economic
- Environmental
13
Q
What are some environmental factors in the spread of disease?
A
- Prevalence of vectors
- Climate conditions
- Natural disasters
- Physical barriers (prevent)
- Proximity to animals
14
Q
What are some social factors in the spread of disease?
A
- Cultural practice
- Migration
- Increased global mobility
- War
- Population density
15
Q
What are some economic factors in the spread of disease?
A
- Sectoral change
- Access to healthcare
- Provision of vaccinations
- Housing quality
- Globalisation
- Developed infrastructure (sewage)
16
Q
What classification of disease is malaria?
A
- Infectious but NON-contagious
17
Q
What 5 diseases do we need to know the global distribution for?
A
- AIDS/HIV
- Tuberculosis
- Malaria
- Cardiovascular disease
- Diabetes
18
Q
Where is malaria concentrated?
A
- Concentrated in: Africa, Latin America, South Asia and South-East Asia.
19
Q
How many people are at risk of malaria and in how many countries?
A
- Overall, 3.2 billion are at risk
- 97 countries
20
Q
How is malaria transmitted?
A
- The malarial parasite (plasmodium) is transmitted via anopheles mosquitos within warm and humid climate.
21
Q
What classification of disease is HIV/AIDS
A
- Infectious AND contagious
22
Q
How is HIV/AIDS transmitted?
A
- The HIV virus is spread by human body fluids such as blood and semen.
23
Q
How many people have a HIV status worldwide, and how many new infections were there in 2024?
A
- 40 million worldwide in 2024
- 1.3 million new cases.
24
Q
What is the distribution of HIV/AIDS?
A
- The main distribution is in sub-Saharan Africa, South Africa and Nigeria.
- Despite this, AIDS/HIV is distributed worldwide, but in lower quantities.
25
How many people contracted TB in 2024, and what was the death toll from the previous year?
- 8 million worldwide
- 1.25 million died in 2023
26
What classification of disease is TB?
- Infectious and highly contagious.
27
What is the global distribution of TB (tuberculosis), and where is the highest mortality?
- TB is present in all global regions, however 95% of deaths occur in LIDCs and EDCs.
- Africa has the highest number of TB deaths, commonly co-morbid with AIDS.
28
What classification of disease is diabetes?
- Non-communicable
29
How many people, in 2024, have diabetes worldwide and how many deaths occur yearly?
- 800 million have diabetes
- 6.7 million die as a result annually.
30
Where is diabetes distributed?
- Diabetes is widespread across both the developed and less developed world.
- Highest concentration is in North America and South Asia.
31
- Where is cardiovascular disease distributed (including what countries have the highest CVD mortality)?
- It is more commonly morbid in aging populations, associated with AC status.
- The countries with the highest CVD mortality are when standardized by age are: Russia, sub-Saharan Africa, and the Arabian peninsula
- 3/4s of CVD deaths are in middle to low income countries (inversely related to income)
32
What is meant by diffusion of disease?
- The way in which disease spreads outwards from its origin across space.
33
What model is used to explain diffusion?
- The Hägerstrand's diffusion model
34
What are the 4 main types of diffusion under Hägerstrand's model?
- Expansion diffusion
- Relocation diffusion
- Contagious diffusion
- Hierarchal diffusion
35
Describe expansion diffusion
- In **expansion diffusion** a disease has a source and spreads outwards into new areas, during this carriers in the source area remain infected.
36
Give an example of a disease outbreak that undergoes expansion diffusion
- A tuberculosis outbreak
37
Describe relocation diffusion
- In **relocation diffusion** a disease leaves the area of origin and moves to new distinct areas.
38
Give an example of disease outbreak that *underwent* relocation diffusion
- The cholera epidemic in Haiti 2010.
- The disease originated in Nepal and was brought by international aid workers.
39
Describe contagious diffusion
- In **contagious diffusion** is where disease spreads through **direct contact** with a carrier, strongly influenced by proximity.
40
Give an example of a disease outbreak that *underwent* contagious diffusion
- The Ebola epidemic in West Africa in 2014-15.
41
Describe hierarchical diffusion
- In **hierarchical diffusion** a disease spreads through an ordered sequence of places, usually from the largest centers with high connectivity to smaller, more isolated centers.
- Hierarchical diffusion is channeled along road, rail and air transport networks that facilitate contact between carriers and a susceptible population.
42
Give an example of disease outbreak that *underwent* hierarchical diffusion
- The COVID-19 pandemic
- This was due to mobility by rail journeys and international air flights.
43
What is included in Hägerstrand's model?
- Expansion diffusion
- Relocation diffusion
- Hierarchical diffusion
- Contagious diffusion
- 'Neighborhood effect'
- Barriers to diffusion
- S-shaped logistic curve
44
What is the neighborhood effect in Hägerstrand's model?
The idea that the probability of contact between a carrier and non-carrier is determined by the number of people residing in a 5x5km grid square, and their distance apart.
45
What does the S-shaped logistic curve represent in Hägerstrand's diffusion model, and explain it
- It represents how the number of people infected by an epidemic approximates an S-shaped or logistic curve over time.
- In this, after a slow beginning, the number infected accelerates rapidly until eventually plateauing, as most of the susceptible population have been infected.
46
What are the two types of barriers to disease in Hägerstrand's diffusion model?
- Socio-economic barriers
- Physical barriers
47
List the 4 *phases* of diffusion in Hägerstrand's diffusion model
- Primary stage
- Diffusion stage
- Condensing stage
- Saturation stage
48
What happens in each *phase* of diffusion in Hägerstrand's model?
- **Primary stage**: there is a strong contrast in disease incidence between the area of outbreak and remote areas.
- **Diffusion stage:** new centers of disease outbreak occur at distance from the source, reducing spatial contrasts seen in the primary stage.
- **Condensing stage:** the number of new cases is more equal in all locations, irrespective of distance from the source.
- **Saturation stage:** diffusion decelerates as the incidence of disease reaches its peak.
49
Describe some socio-economic barriers to disease
- Political border checks
- Imposing curfews or quarantining
- Mandating facemasks in public places such as hospitals
- health education
50
Describe some physical barriers to disease
- Distance between areas
- Mountain / topographical barriers
- Climate conditions
51
What 4 physical factors influence the prevalence of disease?
- Temperature (climate)
- Precipitation (climate)
- Relief
- Water sources
52
How does global patterns of temperature influence patterns of disease?
- Temperature, being part of climate, influences disease.
- Warm temperatures, such as in the Sub-tropics and Tropics, are favored especially by diseases caused by vectors such as malaria and sleeping sickness due to having a warm, humid tropical condition for breeding to occur.
- Colder temperatures, such as in North America and Europe, tends to be favored by respiratory diseases such as influenza, thriving off of the environments influence on the immune system.
53
How does global patterns of precipitation influence patterns of disease?
- Precipitation, being part of climate, works alongside temperature to provide a humid environment - such as in the Tropics that facilitate the reproduction of vectors carrying disease.
- Precipitation also provides aquatic habitats such as ponds and stagnant pools, allowing insects and other vectors to flourish and complete their life cycles.
54
How does global patterns of relief influence patterns of disease?
- A rise in altitude corresponds with lowering temperatures and increasing rainfall.
- In parts of Africa, such as the highlands in Ethiopia being virtually free of malaria whilst the *Western Lowlands* have high prevalence of malaria, this is because higher altitudes are too cold for the mosquito vector to thrive.
- If the topography/relief is flat, floodplains form during periods of flood leading to water-borne diseases such as hepatitis A and dysentery.
55
How does global patterns of water sources influence patterns of disease?
- There is higher stagnant water sources within warmer areas, affecting the prevalence of water-borne diseases and parasites.
56
How do the **4** physical factors in the specification affect the prevalence of vectors (mosquitoes)
- **Precipitation**: Malaria requires mosquitoes to complete their lifecycle and reproduce effectively, this requires precipitation to create stagnant water sources, in turn, average monthly relative humidity needs to be over *60%*.
- **Temperature**: Malaria favors, and is active in places with temperatures averaging between 18-40 degrees annually.
- **Relief**: Mosquitoes favor areas of lower relief due to hosting warmer temperatures in relation to altitude and being vulnerable to flood events.
- **Water-sources**: Mosquitoes require stagnant water for their lifecycle, which includes laying eggs in areas with extensive water sources.
57
In what ways does seasonal variations influence disease outbreaks?
- Winter months lead to peaking epidemics of influenza and respiratory illnesses in the Northern Hemisphere.
- Monsoon seasons in the tropics and sub-tropics lead to an increase in vector-borne diseases such as mosquitoes carrying malaria.
In addition, monsoon seasons allow vectors, such as the tsetse fly (sleeping sickness) in West and Central Africa to extend their lifespan.
- Bilharzia, a disease spread from flatworms and freshwater snails increases with seasonal precipitation and temperature increase above 20 degrees due to their seasonal lifecycle being linked to these events.
58
In simple, in what ways has climate change influenced infectious diseases?
- Climate change, characterized by increase in temperature, rainfall and humidity has *stimulated transmission* of infectious disease and **extended their geographical range**!!
59
How is West Nile Virus affected by climate change?
- West Nile Virus is transmitted via mosquitos, with it's spread being facilitated by climate change bringing warmer and wetter conditions for the vector.
- As a result of climate change, WNV is developing an *extended geographical range*, it is prevalent throughout Africa, In the Americas it is found from Canada to Venezuela and can be traced in parts of Europe, West Asia and Australia.
- The USA has seen how high temperatures favor transmission - hence, Texas being the state most severely effected.
- WNV, as a result of climate change has developed NEW HOSTS in birds.
60
How is Lyme's disease affected by climate change?
- Climate change is responsible for Lyme's disease spreading Northwards as temperatures rise.
- As a result, ticks (the vectors of Lyme's disease) are predicted to colonize Canada.
61
How is sleeping sickness affected by climate change?
- Sleeping sickness is transmitted by tsetse fly, a vector.
- Outbreaks of the disease occur in temperatures in the range of 20.7-26.1 degrees.
- Future climate change will effect the vectors growth rate and geographical distribution of the disease. FOR EXAMPLE: as temperatures rise, sleeping sickness is likely to spread into Southern Africa and affect up to 77 million more - WHO.
- Despite this, a positive is that climate change may mean the disease can disappear completely from East Africa as climate may be too hot for Tsetse larvae to survive.
62
What is an anomaly to the idea that climate change will spread malaria over a wider geographical area?
- Malaria was previously found to be endemic in Europe and other temperate regions, even when climate was colder than in the modern day.
- In addition, even if future climate becomes more suitable for malaria in Southern Europe, parts of Asia and the USA - a large endemic is unlikely here due to availability of anti-malarial drugs and high standards of public health services, associated with ACs.
63
Define what is meant by a zoonotic disease
Diseases spread from animals to humans by viruses, bacteria, fungi and parasites - these include diseases such as malaria, dengue fever, sleeping sickness and rabies.
64
Zoonotic infections can only be transmitted by wild animals, true or false?
False!
- For example, poultry (a domestic animal) present a greater risk of transmitting Asian flu than wild birds.
65
What conditions increase the transmission of zoonotic illnesses to humans?
- There is free movement of infected animals
- Ineffective country controls on the movement of diseased domestic animals
- Urbanization creates new habitats for animals such as foxes, bringing them in closer proximity to humans.
- Sparse vaccination of pets and domestic livestock.
- Lack of animal control for rabid/feral animals
- Hygiene and sanitation are poor, as drinking water sources are contaminated by animal faeces
- There is prolonged contact between humans and animals, for example the wet meat markets in China and farms (poultry with avian flu and cattle with anthrax).
66
What is the link between diseases and levels of economic development (specification point)
As countries develop, the frequency of communicable diseases decreases, whilst the prevalence of non communicable diseases rises. (diseases of affluence)
67
Who created the epidemiological transition?
Omran
68
What does the epidemiological transition describe?
- The model of the epidemiological transition describes the relationship between development and changing patterns of population age distribution, mortality, fertility, life expectancy and causes of death.
- Changes are driven by improvement in health care, standards of living and the quality of the environment
69
According to Omran under the epidemiological transition, what are the 3 epidemiological stages?
- 1) The age of pestilence
- 2) The age of receding pandemics
- 3) Post industrial societies mortality rate slackens
70
What is the proposed 4th stage to the epidemiological transition?
- 4) The age of delayed degenerative diseases
71
What are some criticisms of the epidemiological transition?
- The model is too optimistic
- There is counter-evidence, such as the rate of improvement of life expectancy slowing in developed countries, and even falling in countries such as the UK
- Globalization may increase spread of pandemics, so infectious diseases still remain an issue.
- Development can be attributed to industrial output and destruction of ecosystems - so zoonotic diseases are more easily facilitated
- COVID-19 as an event has reminded us that both governments and populations of the 'developed world' are not immune to communicable disease.
72
Explain what occurs in the 3 stages of the epidemiological transition
- **The age of pestilence and famine**
Pre-industrial societies see high mortality and low life expectancy. Poor sanitation, contaminated drinking water and low standards of living make people susceptible to infectious diseases. Population growth is slow and intermittent.
- **The age of receding pandemics**
Industrial societies see advances in medical technology, diet and hygiene, and also improvements in living standards. Epidemics causing large scale mortality become rare, life expectancy rises above 50 and population growth is sustained. There is a shift from main death being caused by infectious diseases to chronic and degenerative diseases.
- **Post-industrial rate of mortality slackening**
Further improvements in medical technology, hygiene and living standards means that mortality related to infectious disease is rare. Degenerative disease becomes the main cause of mortality.
73
For what reasons do ACs have a higher prevalence of non-communicable diseases?
- Lengthened life expectancies inevitably increases the proportion of deaths and illnesses connected to degenerative diseases and aging.
- Overnutrition and excessive consumption of sugar, carbohydrates, fats and salt are increasing NC diseases such as CVD, type-2 diabetes, hypertension etc..
- Sectoral change, and higher incomes, increases office jobs which requires minimal physical activity. This allows accessibility to food such as meat, leading to overconsumption of this.
- Standards of living rising has a correlation with prevalence of non-communicable diseases - cancers are higher in ACs compared to LIDCs and EDCs. Cancer rates are over double in ACs compared to LIDCs.
74
For what reasons do LIDCs have a higher prevalence of communicable diseases?
- Communicable diseases can be categorized into 3: animal-borne, water-borne and food-borne.
- Waterborne diseases remain endemic in LIDCs, and are eliminated in ACs - this is due to lack of infrastructure.
- There is failure to control communicable disease outbreak due to economic state limiting healthcare services and resource provision to tackle this.
- Other factors are malnutrition which is associated with immunosuppression, and lack of resistance to common diseases.
- Many LIDCs witness overcrowding of housing in urban areas, stimulated by work opportunities - this is closely linked to respiratory air-borne disease spread.
- **Environmentally**, LIDCs are common in areas such as the tropics and sub-tropics - climate creates ideal conditions for a wide range of infectious diseases (despite Singapore being an exception with a life expectancy of over 84 years).
75
What is an international organization involved in diseases?
The World Health Organization
76
What are the main roles of the WHO?
- Data collection and research
- Providing leadership in health matters
- Monitoring international health
- Supporting UN member states to devise health strategies
- Providing support during health crises
77
To be concise, what are the 4 main activities of the UN?
- Data collection
- Providing leadership for health matters
- Technical support
- Research and monitoring
78
Outline the role of the WHO in data collection.
- The WHO collects data from its 194 member states.
- The data collected is published annually in its *World Health Statistics*
- This data provides valuable insights into health risk, mortality and government spending.
79
What are limitations to data collection under the WHO?
- The quality and completeness of data is highly variable
- WHO receives causes of mortality data from only 100 member states
- Globally 2/3 of all deaths are not even registered
80
Outline the role of the WHO in research
- The WHO has many different groups dedicated to different diseases such as influenza, tropical diseases, mental health and vaccination efforts.
- These often partner with different agencies, such as the multi-agency 'Stop TB Partnership', aiming to eradicate TB by 2050.
81
In what way has WHO offered support programs to member states?
- The 2015 Nepal earthquake: delivered emergency health services via mobile medical units, and supported foreign medical teams.
- Liberia Ebola: WHO responded to the collapse of Liberia's health care services alongside UNICEF by stepping in and organizing country wide measles vaccination programs.
82
What is an example of a disease outbreak at global scale?
COVID-19.
83
What was the role of the WHO during COVID-19?
- WHO picked up reports of a viral pneumonia in Wuhan in January 2020, as well as acknowledging that it was infectious and transmitted from human-to-human.
- WHO declared a global pandemic on March 11th
- WHO advised governments on course of action during COVID-19, such as quarantine
84
How did governments respond in different ways during COVID-19, and does this weaken the role of the WHO?
- Many governments had different responses to quarantine
- In East Asian countries such as South Korea and Taiwan were best prepared due to confronting SARS illnesses before.
- Advanced countries such as European nations and the USA underestimated and underfunded preparation for pandemics.
- Donald Trump froze WHO funding, claiming that it had failed its duty and accused it of being 'China-centric'.
- This undermines the role of the WHO as they only have an advisory role, which is able to be ignored by leaders, and they rely on funding from governments.
85
What were the patterns of outbreak distribution of COVID-19?
- COVID had the greatest impact on poor people within high density locations.
- Mortality rates varied greatly between countries, and even within them.
- In some (but not all) LIDCs and EDCs, the impact was especially severe due to pressure on public services, high urban densities and poverty.
- Social distancing and effective quarantine was inhibited in slums due to high densities, and the necessity of leaving home to work and produce income.
86
What 2 types of barriers to disease are there?
- Physical barriers
- Human barriers
87
What is the role of physical barriers of disease?
Isolating communities and restricting population movement
88
Are physical barriers to disease always positive?
- Nope
- Despite reducing spread, events such as disease outbreaks in remote communities may delay the arrival of medical assistance and emergency aid
89
What are examples of physical barriers to disease, outlined in the spec?
- Relief
- Natural hazards
- Excess water
- Remoteness of communities
90
What is an example of remoteness being a positive aspect as a physical barrier?
- Maryland, USA
- Chesapeake Bay divides the state into two distinct regions
- The bay acts as a barrier to population movements, which limited the spread of measles in the early 1900s.
91
What is an example of remoteness being a negative aspect as a physical barrier?
- Nepal following the 2015 earthquake
- Waterborne diseases such as cholera broke out in the remote Gorkha region that were cut off by landslides, in addition to remoteness
- It took 2 weeks for aid to arrive, so cholera (a relatively containable epidemic) took hold.
92
What were the human and environmental causes of COVID?
- It is heavily disputed
- Dominant theory is that it originated in bats or pangolins, which was transmitted to humans
- Reports suggest that the 'wet markets' selling seafood and meat spread the virus in Wuhan
93
What were the socio-economic impacts of COVID?
- The governments either had to impose restrictions of lockdown, quarantine and restrictions on movement.
- The death rate was higher in older populations, yet younger populations were impacted in terms of job losses and interruption of education.
94
What country saw relative success with combatting COVID?
Cuba
95
What did Cuba do, as a national government, to control COVID?
- Cuba immediately established a commission to deal with Covid-19, set up in mid-January 2019 before cases emerged elsewhere.
- They updated their **National Action Plan for Epidemics**.
- From March, all arrivals were tested upon entry - and lockdown begun.
- Borders were closed to non-residents soon after
- As a result, death rates *fell to normal levels for the time of year* in July.
96
How did Cuba deal with the effects from COVID?
- Economic measures were put into place to help businesses and individuals in lockdown, for example *anyone hospitalized received 50% of their salary guaranteed from the state*.
97
Why is Cuba a surprising story in how they dealt with COVID?
- Cuba has a relatively lower socio-economic status compared to ACs such as America, yet had more effective lockdown procedures
- This shows that Cuba's performance bares comparison with much wealthier, and theoretically more resourced countries.
98
Why are medicinal plants threatened?
- 80% of the developing worlds population relies on traditional medicine, so species collected and marketed are under enormous pressure.
- Deforestation in the tropics threatens plants, as the tropics contain 70% of terrestrial plant species.
99
At least how many potential major drugs are lost every two years due to tropical deforestation?
At least 1, according to the Centre for Biological Diversity
100
What is meant by biopiracy?
The exploitation of medicinal drugs from wild environments by pharmaceutical companies, which has little or no benefit to the indigenous
101
What are conservation issues with extracting medicinal plants?
- Endangering species survival
- Erosion of genetic diversity
- Threat to survival of natural ecosystems
102
What eradication had been successful, and which eradications have not yet been successful?
- Successful: smallpox
- Unsuccessful: malaria and hook worm
103
Outline global campaign attempts to eradicate polio
- The Global Polio Eradication Initiative (supported by WHO, UNICEF and others) begun in 1960s
- This eliminated polio from the Americas
- By 2011, the polio virus was only endemic in 3 countries: Afghanistan, Pakistan and Nigeria - due to uneven uptake of vaccines offered
104
What is a negative of global initiatives to vaccine children?
- Universal support should not be assumed
- Political instability, such as in Nigeria and Pakistan led to healthcare worker deaths which interrupts vaccination programmes
- In addition, war-torn countries such as Syria where healthcare has broken down has seen new outbreaks
- There is also resistance to vaccination due to political and cultural factors
105
What is a small case study for a national campaign of disease eradication?
Mauritius 1973 malaria eradication
106
In what way did Mauritius initially eliminate malaria?
- **Top down national initiatives** were successful
- Initially, malaria was endemic in the mid-19th century, and killed 1/8 during an epidemic
- It was eliminated through a government backed campaign between 1948-51, buildings and breeding sites were sprayed with insecticides.
- Mortality rates were reduced from 6/1000 to 0.6/1000, allowing WHO to declare them malaria free in 1973
107
How have Mauritius currently eliminated malaria and going forward
- Following Hurricane Gervaise, an epidemic forced a second elimination campaign.
- Mosquito breeding sites and indoor spraying continued, as well as introducing predatory fish. Chloroquine was administered on mass to the population
- Since 1988, prevention of the reintroduction of malaria has involved rigorous passenger screening at the airport, screening 174k passengers yearly
- Only one case, that was imported, has occurred since in 1997
108
What is an alternative strategy to eliminating disease as opposed to 'top-down' levels from governments
Grass root strategies
109
What are 'grass-root strategies'
- Strategies, usually administered by NGOs, that involves and empowers local communities in the case of disease
110
What is an example of a 'grassroot' elimination programme?
Guinea Worm eradication programme in Ghana
111
Outline the grassroot guinea worm eradication programme in Ghana
- In Ghana, the Guinea worm eradication programme has partnered with Ghana Red Cross women's clubs to reduce transmission of guinea worm.
- It involves teaching women volunteers how the guinea worm is transmitted and how this transmission can be prevented.
- Volunteers then visit villages and educate local communities
112
Using Guinea worm as an example, why do grass-root strategies usually involve women?
- There had been limited success of using male volunteers, as they usually work outside villages, whilst women are responsible for sourcing water and its household consumption.
113
What are the responsibility of the Ghana Red Cross women's club volunteers in eliminating Guinea worm?
- Monitoring, identifying and reporting all new cases of Guinea worm
- Ensuring infected do not contaminate water sources
- Distribute, check and replace water filters
- Identify water sources used by the community requiring treatment with larvicide.
114
What has been the relative success of the Guinea worm grassroot eradication programmes?
- It has been highly successful - and has been effectively eradicated from Ghana
- WHO reported there were over 150 cases in 1989, and by 2010 was the last report of an indigenous case of disease
- Despite this, NGOs were still relied upon - as well as funding from organizations such as the Gates Foundation
