March is Endometriosis Awareness Month

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Test your knowledge

An estimated 11 percent, or nearly 7 million women in the U.S. have endometriosis.

That’s more than the number of women who suffer from asthma (9.8%), more than the number of women who suffer from heart disease (6.2%), and it is just slightly less than the number of women who will develop breast cancer during her lifetime (13%).

It effects a lot of women every day.

Endometriosis is a health condition that involves tissue that typically grows in the uterus or womb but begins to grow where it shouldn’t. When this happens, it can cause pain, digestive problems, and even infertility. It can happen to any female, but it is more common in women who are in their 30s and 40s.

Signs and symptoms

The pain women feel is the most common symptom of endometriosis. However, the pain is different for different women, including:

  • Pain in the lower back and pelvis that doesn’t go away
  • Painful menstrual cramps
  • Intense discomfort in the intestines or during bowel movements
  • Pain after or during sex

It is important to know that how intense or severe the pain is, doesn’t matter. People with mild pain could have a more advanced case of endometriosis. The pain can also increase over time.

Treatment and prevention

After a doctor does a full exam and diagnoses a patient with endometriosis, there are a few different types of treatment options to discuss.

Medication – Some medications will likely include hormones, usually a hormonal birth control pill or implant, as a starting point. Hormones aren’t a permanent solution but will typically provide some relief of the pain and reduce the additional growth of endometriosis.

Surgery – If medicine isn’t helping, your endometriosis is severe, or you can’t get pregnant, your doctor may suggest surgery. You will likely start hormone medication after the surgery if not trying to get pregnant.

Other treatments – Over the counter pain medicine like acetaminophen (Tylenol) or ibuprofen (Motrin or Advil) can help with discomfort. Some women have relief with other things like acupuncture and herbal supplements, but there is no research or proof that these things provide consistent relief.

There is good news and bad news about preventing endometriosis. The bad news is you can’t prevent it. The good news is that there are a number of things you can do to decrease your odds of developing it. Because endometriosis is tissue that grows with increases of the hormone estrogen, the goal is to keep that level low with:

  • Regular exercise which helps reduce body fat, which then reduces estrogen.
  • Reducing or eliminating caffeine because it can increase estrogen levels.
  • Opting for a low-dose hormonal birth control pill, patch, or ring.
  • Reducing or eliminating alcohol because more than one drink per day can rise your estrogen levels.

Pregnancy and endometriosis

How endometriosis affects a woman’s ability to get pregnant isn’t fully known. But many women – as many as half – with fertility problems had endometriosis. The good news is that many women can still get pregnant! Each patient is different, and every patient’s doctor will recommend the best approach.

Having a medical home with consistent medical exams and conversations with a comprehensive medical team is the best approach. NOAH’s providers work with patients of all ages and health backgrounds. Learn more and make an appointment today.

Honoring Black History in Healthcare: Week 4 – Enslaved Women and Modern Gynecology

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Throughout February, NOAH will share and honor Black History Month with snapshots of just a few of the important, impactful, and life-saving stories of Black history in healthcare in America. One of our primary goals at NOAH is ensure quality healthcare for every member of our community. To do that, we will look at where we have been, what we have accomplished, and how we will collectively achieve this goal.

Enslaved Women and Modern Gynecology

By By Jennifer Perry, MD, PGY-3

Dr. James Marion Sims has been named the “father of modern gynecology” for his contribution of tools, such as the speculum, and surgical techniques related to women’s health. He was named president of the American Medical Association in 1876 and president of the American Gynecological Society in 1880. However, Dr. Sims’ success has overshadowed the suffering of enslaved women that contributed to his work.

Seven women participated in Dr. Sims’ experimentation over a four-year period. Lucy, an 18-year-old who was unable to control her bladder after a traumatic birth, was his first subject. She had a vesicovaginal fistula, a connection between the bladder and uterus which wasn’t uncommon for women who endured traumatic deliveries in the 19th century. Dr. Sims placed naked Lucy on her knees and elbows with her head in her hands for the procedure while several male doctors watched. The entire surgery was conducted without anesthesia. As imagined, Lucy experienced extreme pain as Dr. Sims operated. A sponge was placed in Lucy’s bladder to drain the urine, which led to severe infection. Lucy almost lost her life, but this did not stop Dr. Sims from performing a similar procedure on six other enslaved women.

Enslaved women were considered property and did not need to give their consent for medical procedures. Dr. Sims performed more than 30 surgeries on one woman, Anarcha, without anesthesia. Despite reports of displayed agony, including screaming, it was believed that Black people did not experience pain like White people, so anesthesia was not utilized. However, once Dr. Sims perfected his technique, he performed surgery on White women under anesthesia.

Statues of Dr. Sims have been erected in Central Park and Philadelphia in dedication to his contribution to medicine. Those statues have sparked many protests because of the controversy of honoring a man who performed non-consensual medical experiments on Black women. The New York City statue was moved out of Central Park in 2018, and to Dr. Sims gravesite in Brooklyn, NY. In the same year, the monument in Philadelphia was removed and replaced by a plaque that educates the public of the origins of the monument and the Black females whose bodies were used for the advancement of medicine.

To learn more about the medical ethics involved with this story, read this article from the Journal of Medical Ethics.

Read our other Black History in Healthcare stories:

Week 1: The Innovations of Dr. Charles Richard Drew

Week 2: Understanding the Tuskegee Study

Week 3: The Lasting Impact of Henrietta Lacks

Nutrition Impacts Your Heart Health

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By Brandon Bolton, RDN |Nutrition Educator

February is American Heart Month, so let’s raise awareness and support for heart health in the fight against heart disease!

According to the American Heart Association, heart disease is the number one killer in the United States, and it is the leading cause of death worldwide. There are many risk factors that impact your chances of having heart disease. The National Institutes of Health (NIH) states that preventing heart disease starts with knowing what your risk factors are and what you can do to lower them.

Some risk factors for heart disease include:

  • high blood pressure
  • high blood cholesterol
  • obesity
  • diabetes
  • smoking
  • lack of physical activity
  • unhealthy eating behaviors

These risk factors can be managed or changed. Some risk factors that cannot be changed include age, sex, and family history of heart disease.

If you have any questions or concerns about potential risk factors, please check with your NOAH healthcare provider!

As a Registered Dietitian Nutritionist, I provide nutritional care and guidance for patients with nutrition-related conditions like diabetes and pre-diabetes, cardiovascular disease, weight management, digestive issues, food allergies, and more.

Advice to living a heart-healthy life

Heart disease is often preventable when people make healthy changes, including diet and how much activity or exercise they get. Living a heart-healthy life means knowing your risk factors and making good choices to protect your heart and stay healthy. Here are some heart-healthy nutrition and exercise tips:

  • Choose heart-healthy foods and eat a diet that is balanced with whole grains, fruits and vegetables, and lean protein sources.
    • Try to have at least half of your grain intake come from whole grains such as 100% whole wheat bread, oatmeal, brown rice, and quinoa.
    • Aim for 1-2 cups of fruit daily
    • Aim for 1-3 cups of vegetables daily
  • Choose fat-free or low-fat dairy products when having milk, cheese, or yogurt.

Foods to enjoy

  • Lean meats such as 95% lean ground beef or pork tenderloin, or skinless chicken or turkey (limit red meats to one time per week)
    • Fish such as salmon and tuna (try to eat fish as least once per week)
    • Eggs
    • Nuts, seeds, tofu, tempeh, edamame
    • Legumes such as beans, lentils, and chickpeas
  • Incorporate foods that are high in monounsaturated and polyunsaturated fats (good fats):
    • Olive oil or avocado oil
    • Fish and seafood
    • Nuts and seeds
    • Nut and seed butters
    • Avocados

Foods to limit

  • Limit high sodium foods. Adults and children 14+ should eat less than 2,300 mg of sodium daily.
    • Read food labels and choose foods that are lower in sodium. Look for low sodium, reduced sodium, or no salt added on the food label.
    • Choose fresh, whole foods whenever possible and try to avoid processed foods such as frozen meals.
    • Avoid the saltshaker and flavor foods with herbs and spices instead.
  • Limit saturated fats.
    • Saturated fat is usually found in animal-based proteins such as fatty beef, pork, and chicken skin.
    • It is also found in full-fat dairy products such as whole milk.
    • Butter, lard, coconut and palm oils also contain saturated fats (replace with olive oil).
  • Avoid trans fats.
    • Trans fats can be found in margarine, shortening, processed sweets, baked goods, and some fried foods.
    • Avoid foods with “partially hydrogenated oil” on the ingredient list such as cookies, pastries, baked goods, biscuits, crackers, and frozen dinners.
  • Limit foods that are high in added sugars
    • Sugar-sweetened drinks such as soda, fruit juice, sweetened coffees, and energy drinks
    • Sweets and desserts
  • Limit Alcohol

If you have any nutrition questions or need help developing a heart healthy diet plan, please reach out to one of the dietitians here at NOAH and make an appointment today!

Honoring Black History in Healthcare: Week 1 – The Innovations of Dr. Charles Richard Drew

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Throughout February, NOAH will share and honor Black History Month with snapshots of just a few of the important, impactful, and life-saving stories of Black history and healthcare in America. One of our primary goals at NOAH is ensure quality healthcare for every member of our community. To do that, we will look at where we have been, what we have accomplished, and how we will collectively achieve these goals.

Week 1: The Innovations of Dr. Charles Richard Drew

By Karina Luera, DO, PGY-1

Dr. Charles Richard Drew, an African American surgeon born in 1904, is known as the “Father of Blood Banking” for his significant contributions to the process of blood plasma preservation.

Dr. Drew attended medical school at McGill University in Montreal, Canada and became interested in blood transfusion during his residency work in fluid resuscitation for shock. Later, he was awarded a Rockefeller fellowship at Columbia University where he wrote his thesis “Banked Blood: A Study in Blood Preservation” for his Doctorate in Medical Science. His research led to an appointment as the Medical Director of the Blood for Britain Project (BFB) during World War II, a program in which he implemented a uniform procedure for collecting and processing blood and plasma, successfully collecting over 14,000 blood donations.

Shortly after completing his work with the BFB, he was appointed assistant director of a national blood banking program in the US, sponsored by the American Red Cross where he developed one of his greatest innovations, mobile blood donation units. His work paved the way for the development of modern blood storage and transfusions.

Dr. Drew faced several racial barriers throughout his life, including being denied training and research opportunities. Most ironically, he was unable to donate blood to the very programs he helped establish at the American Red Cross due to their policies preventing Black people from donating blood. The policy was later modified but still required blood donations from Black and White people to be stored separately.  

In response to the policies of the American Red Cross, he resigned from his position and began teaching at Howard University as the Head of the Department of Surgery while also serving as the Chief of Surgery at Freedmen’s Hospital. His mission was to train young African American surgeons to the highest standards. He was the first Black person to be appointed an examiner for the American Board of Surgery. Additionally, he continued to campaign against the exclusion of Black physicians from local and national medical organizations, including the American Medical Association.

Dr. Drew died tragically in a car accident at the age of 46. In his short lifetime, he broke through many racial barriers and made significant contributions to the fields of science and medicine.

Read our other Black History Month snapshots:

Week 2: Understanding the Tuskegee Study

Week 3: The Lasting Impact of Henrietta Lacks

Week 4: Enslaved Women and Modern Gynecology

Understanding Thyroid Disease

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The thyroid is a very important organ that – frankly – doesn’t get the attention it deserves, until something goes wrong, like getting diagnosed with thyroid disease. Here at NOAH, we want to turn our focus here for Thyroid Awareness Month.

What is the thyroid?

The thyroid is a small, butterfly-shaped organ in the front of your neck that wraps around your trachea (throat or windpipe). Its job is to create and release important substances to help your body function. In the case of the thyroid, its job is to release hormones that control your metabolism.

Why is the thyroid important?

The thyroid has an important job to do – regulating your metabolism. Your metabolism is how your body turns food into energy. When your thyroid is working correctly, you don’t think about it. It adjusts the amount of hormones it releases to meet what your body needs. Then, the thyroid creates more hormones and continues the process. Pretty nice.

But like with many things, we don’t notice or appreciate it when it works correctly. However, when the thyroid has trouble doing its job, the results can be serious.

What happens when the thyroid doesn’t work correctly?

Thyroid disease can be caused by two different types of problems with the thyroid: making too much hormones or making too little.

  • Hyperthyroidism is when your thyroid makes too much of the hormones needed to regulate your metabolism. Then, your body uses the hormones too quickly. It can cause people to feel anxious, lose weight too quickly, have trouble sleeping, and make your heart beat faster.
  • Hypothyroidism is when your thyroid doesn’t make enough of the hormones needed to regulate your metabolism. With too little hormone, you can also feel overly tired, gain weight, experience forgetfulness, and feel discomfort with cold temperatures.

Both are serious medical conditions and should be diagnosed and treated by your medical provider.

How do you get thyroid disease?

The risks for thyroid disease are broad and it effects around 20 million Americans. It can be genetic and passed down from family members, but other risk factors include having another medical condition. It’s worth noting that while anyone can have thyroid disease, women are five times more likely to be diagnosed than men, and people age 60 and older are also at a higher risk.

Are there diagnoses and treatments?

Because the signs and symptoms for thyroid disease can look like other illnesses, it is important to talk with your doctor if you have any new symptoms. Your medical provider will do physical exams and most likely blood tests to confirm a thyroid condition.

Treatments will depend on what type of thyroid disease you have and how serious it is. Most patients are prescribed medications.

Many people live healthy, normal lives with thyroid disease, but this thyroid awareness month it is important to learn all about it for yourself and for others. Working with your medical provider and integrated care team at NOAH will make it easier to navigate this or any other health concern or diagnosis.

How Important is Healthy Skin?

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Did you know your skin is the largest organ in your body? Your skin protects you, tells you a lot about your overall health, and it grows and changes with you throughout your life. Our skin has a big job to do, which is why keeping skin healthy is so important.

Here are some useful tips to keep your skin healthy at every age.

Pay Attention to Dry Skin

Dry skin can be the result of environmental factors, or it can be because of what is happening inside our bodies. Either way, pay attention to it and hydrate your skin. Drinking a lot of water – 8 glasses – throughout the day, is one of the best things you can do for your skin (and other parts of your body!).

Dry skin can also become a problem if not treated with itching, flaking, even bleeding from dry skin. Many of us in Arizona have to deal with “hard water”, or water heavy in calcium and magnesium. This can make it harder for soap to wash off your skin, so spend a few extra seconds rinsing your hands, face, and body. Moisturize with ointments, creams or lotions after showers, baths, and handwashing, but make sure they don’t contain alcohol which can have the opposite effect.

Baby’s Skin Can Have Different Needs

Babies are a wonder, and so is their skin! Baby acne, birthmarks, diaper rash, hives, eczema, and others are common in babies, but they are things all new parents and caregivers should be familiar with. The American Academy of Dermatology Association has detailed information about these conditions and many more. If you ever have questions about your baby’s skin, talk to your NOAH provider.

Protect Your Skin from the Sun

The great news is that sunscreen is both the easiest and best way to protect your skin from harmful ultraviolet rays. Try for SPF 30 and wear it all year on whatever part of you isn’t protected by clothing – think hands, arms, face. Sun can cause skin aging and increase certain types of skin cancer.

Everyone deals with some types of skin troubles during their life. Whether it is acne, blackheads, rashes, or dry skin, it is helpful to know how to protect your skin and when it’s time to call your provider. If you have any questions, make an appointment with your provider.

Recognizing the Impact of Antibiotics

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By Cody Randel

Antibiotics save and improve countless lives every day. However, antibiotic resistance is something we need to understand and face together. November 18 – 24 is Antibiotic Awareness Week in the U.S. and World Antimicrobial Awareness Week on a global scale. Antimicrobial resistance of any kind can impact everyone.

Antibiotics are part of the antimicrobial family, which also includes antivirals, antifungals, and antiparasitics. These medicines kill infections and diseases. Without them, humans will have a much more difficult time fighting and surviving diseases. Fortunately, the World Health Organization (WHO) saw this growing problem and has made it a priority. Because diseases become more difficult to treat as antibiotic resistance increases, it will make all antimicrobials less effective.

WHO’s Five Goals to Tackle Antimicrobial Resistance

  • Raise awareness 
  • Increase monitoring and research
  • Reduce infections
  • Maximize the use of antimicrobial medications 
  • Sustainable investment in new medicines, diagnostic tools, vaccines, and other interventions

We rely on antibiotics to help us recover from what may seem like minor illnesses today. But these illnesses could become life-threatening if antibiotic resistance increases.

Preventing Antibiotic Resistance

Antibiotic resistance is increasing in all parts of the world. Changing this is a big job that requires all of us to do our part. Here are six ways you can help:

  • Only use antibiotics prescribed to you by a certified health professional.
  • Never demand antibiotics from your health worker. If you need them, they will prescribe them.
  • Always follow directions for taking medications.
  • Never share any prescriptions.
  • Prevent illnesses by washing your hands and staying away from people who are sick.
  • Get vaccinated and stay up to date on seasonal vaccines like flu.

If you have questions about medications you are taking, or about vaccines you may need, talk to your healthcare provider. If you don’t have a primary care provider, request an appointment with one of our providers.

Get Some Relief During TMJ Awareness Month

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Millions of people in the United States are living with TMJ (Temporomandibular Joint) disorder and have no idea that it is the source of their pain and discomfort. TMJ disorder, or TMD, is pain in the jaw and surrounding tissues. Symptoms and issues from TMD can range from mild or occasional discomfort, to more severe pain and disruptions to daily life.

It’s estimated by the TMJ Association that around 35 million people in the United States are affected by this disorder. That’s around 12% of the population and most of these people are women.

Why TMJ Disorder matters

Symptoms can range from things like headaches and migraines, neck and shoulder pain, jaw pain or stiffness to other symptoms like dizziness, and even ear pain or ringing. Finding the cause – and a solution – to these symptoms can make a big difference in your life. If left untreated, TMD can cause damage to your teeth, joint, muscles, and tissues, so you want to talk to your healthcare provider about it.

What are the causes

  • Injury or trauma to your jaw or face
  • Arthritis
  • Unaligned bite
  • Stress
  • Genetics
  • Hormones

Treating TMJ Disorder

Most jaw and facial muscle pain is temporary and will go away on its own. If it doesn’t go away in a few weeks, visit your dentist or primary care doctor to rule out any other causes. A few things you can do on your own include:

  • Eat soft foods
  • Reduce stress or talk with someone about your stress
  • Use ice or heat on the jaw or muscles
  • Avoid chewing gum and wide yawns
  • Don’t hold the phone with your shoulder
  • Sleep on your side with a pillow supporting your neck

TMJ disorder is something many people live with. And for some people, the symptoms will come and go. If you are someone who has lasting symptoms, talk to one or our healthcare providers.

Ten Basic Rules for Emotional Health

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In light of May being deemed Mental Health Awareness Month in the U.S., here are some keys to creating and maintaining emotional wellness.

  1. Take care of yourself. Take time to relax, exercise, eat well, spend time with people you enjoy and activities which you find pleasurable.
  2. Choose to find the positives in life experiences instead of focusing on the negatives. Most clouds have a silver lining and offer opportunities for personal understanding and growth. When you accept that things are sometimes difficult, and just do what you need to do, then it doesn’t seem so hard.
  3. Let go of the past. If you can’t change it, and you have no control over it, then let it go. Don’t waste your energy on things that cannot benefit you. Forgive yourself and others.
  4. Be respectful and responsible.
  5. Acknowledge and take credit for your successes and accomplishments.
  6. Take the time to develop one or two close relationships in which you can be honest about your feelings.
  7. Talk positively about yourself and about others.
  8. Remove yourself from hurtful or damaging situations. Temporarily walk away from a situation that is getting out of control.
  9. Accept that life is about choices and is always bringing change to you. Accept that change also requires personal adjustment.
  10. Have a plan for the future. Develop long range goals for yourself, but work on them one day at a time—or even one minute at a time.

We know these things aren’t always as easy as they seem. We are here for you on your journey to wellness!

Know the Facts about Children and Diabetes by Dr. Jain, Pediatrician and Brandon Bolton, RDN

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The Defeat Diabetes Foundation (DDF) has named April Defeat Diabetes Month. Defeat Diabetes Month is a time to raise awareness about diabetes prevention, management, and treatment throughout our communities. At NOAH, we are here to help you through all aspects of defeating diabetes, from awareness through treatment.

There are multiple forms of diabetes, but the two most common forms are called type 1 and type 2 diabetes mellitus. Both forms can occur at any age, but a child is typically more likely to be diagnosed with type 1 diabetes. However, with childhood obesity rates on the rise, the number of children diagnosed with type 2 diabetes or who are at risk of developing type 2 diabetes later in life is also increasing. According to the DDF, 1 in 3 US children is overweight or obese. 75% of these children will become overweight or obese adults, and 87.5% of adults diagnosed with type 2 diabetes in the US are overweight or obese.

The DDF has created three different steps to help win the fight to defeat diabetes. The three steps include awareness, action, and prevention.

  • Awareness – creating awareness of the risk factors, warning signs, and complications.

Diabetes is a chronic disease that is characterized by high levels of glucose (sugar) in the blood. Insulin is needed to help lower the levels of sugar and maintain normal blood sugar levels. Diabetes occurs when insulin is not produced in sufficient amounts or the cells of the body are unable to use the insulin properly. Over time, high blood sugar levels may lead to serious complications such as diseases of the eyes (retinopathy), kidneys (nephropathy), nerves (diabetic neuropathy), and blood vessels (that can eventually lead to poor circulation in the extremities). Diet and lifestyle changes can help decrease the risk of these complications.

Type 1 diabetes is a chronic disease that is almost exclusively based on genetics, and it cannot be prevented. With type 1, the pancreas produces very little or no insulin, leading to high blood sugars. Symptoms include increased urination, excessive thirst, increased appetite, and weight loss.

Type 2 diabetes is highly preventable and can be characterized by insulin resistance, decreased insulin production, or a combination of both. Some of the modifiable risk factors for type 2 diabetes include diet, physical activity, and weight management.

  • Action – taking action and providing individuals with the information they need to make the right dietary, lifestyle, and treatment choices to ensure their optimal health.

It’s important to talk with your child’s doctor to find the best treatment plan. Your child’s doctor will talk you through the importance of lifestyle, diet, and medication in order to keep your child’s blood sugar under control. Eating healthy and maintaining an active lifestyle can help manage BOTH type 1 and type 2 diabetes. As mentioned, Type 2 diabetes is highly preventable, so it is even more important to start creating healthy nutrition and lifestyle habits at a young age.

Children who are at risk or are diagnosed with diabetes can live a happy, healthy life through self-management and with an integrative team approach with various medical professionals. An integrated approach with your child’s doctor, a registered dietitian, and a behavioral health specialist can help develop a nutrition, physical activity, and medication plan that can help.

Here are some healthy nutrition tips from The American Academy of Pediatrics:

  • Eat at least 5 servings of fruits and vegetables each day.
  • Stick with water, avoiding juices and other drinks high in sugars.
  • Include high-fiber, whole-grain foods such as brown rice, whole-grain pasta, corns, peas, and breads and cereals at meals. Sweet potatoes are also a good choice.
  • Choose lower-fat or fat-free toppings like grated low-fat Parmesan cheese, salsa, herbed cottage cheese, nonfat/low-fat gravy, low-fat sour cream, low-fat salad dressing, or yogurt.
  • Select lean meats such as skinless chicken and turkey, fish, lean beef cuts (round, sirloin, chuck, loin, lean ground beef—no more than 15% fat content), and lean pork cuts (tenderloin, chops, ham). Trim off all visible fat. Remove skin from cooked poultry before eating.
  • Include healthy oils such as canola or olive oil in your diet. Choose margarine and vegetable oils without trans fats made from canola, corn, sunflower, soybean, or olive oils.
  • Use nonstick vegetable sprays when cooking.
  • Use fat-free cooking methods such as baking, broiling, grilling, poaching, or steaming when cooking meat, poultry, or fish.
  • Serve vegetable and broth-based soups or soups that use nonfat (skim) or low-fat (1%) milk or evaporated skim milk when making cream soups.
  • Use the Nutrition Facts label on food packages to find foods with less saturated fat per serving. Pay attention to the serving size as you make choices. Remember that the percent daily values on food labels are based on portion sizes and calorie levels for adults.
  • Prevention – take a personal pledge to prevent diabetes in your family and your community.

Feel free to reach out to one of your NOAH Health Centers with any questions you may have. NOAH offers a full range of primary and preventable health services for all ages!

To learn more about the DDF and the prevention and management of diabetes, visit their website at https://defeatdiabetes.org/

To read more about Type 1 Diabetes in children visit https://www.healthychildren.org/English/health-issues/conditions/chronic/Pages/Diabetes.aspx

To learn more about type 2 diabetes and tips for healthy living check out https://www.healthychildren.org/English/health-issues/conditions/chronic/Pages/Type-2-Diabetes-A-Manageable-Epidemic.aspx