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Suppurative sequelae virus e68 generic stromectol 3 mg without prescription, such as peri to virus epstein barr cost of stromectol nsillar abscesses and cervical adenitis antibiotics wiki buy stromectol paypal, usually are prevented by treatment of the primary infection virus headache purchase stromectol discount. Children with strep to coccal pharyngitis or skin infections should not return to school or child care until at least 24 hours after beginning appropriate anti microbial therapy. The risk of recurrence decreases as the interval from the most recent episode increases, and patients without rheumatic heart dis ease are at a lower risk of recurrence than are patients with residual cardiac involvement. The intramuscular regimen has been shown to be the most reliable, because the success of oral prophylaxis depends primarily on patient adherence; however, inconvenience and pain of injection may cause some patients to discontinue intramuscular prophylaxis. Oral sulfadiazine is as effective as oral penicillin for secondary prophylaxis but may not be available readily in the United States. By extrapolating from data demonstrating effective ness of sulfadiazine, sulfsoxazole has been deemed an appropriate alternative drug. Allergic reactions to oral penicillin are similar to reactions with intramuscular penicil lin but usually are less severe and occur less commonly. Severe allergic reactions in patients receiving continuous penicillin G benzathine prophylaxis also are rare. Rare reports of anaphylaxis and death generally have involved patients older than 12 years of age with severe rheumatic heart disease. Most severe reac tions seem to represent vasovagal responses rather than anaphylaxis. Prevention of rheumatic fever and diagnosis and treatment of acute strep to coccal pharyngitis. Chemoprophylaxis for Recurrences of Acute Rheumatic Fevera Drug Dose Route Penicillin G benzathine 1. Prevention of rheumatic fever and diagnosis and treatment of acute strep to coc cal pharyngitis. A scientifc statement from the American Heart Association, Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Reactions to continuous sulfadiazine or sulfsoxazole prophylaxis are rare and usu ally minor; evaluation of blood cell counts may be advisable after 2 weeks of prophy laxis, because leukopenia has been reported. Prophylaxis with a sulfonamide during late pregnancy is contraindicated because of interference with fetal bilirubin metabolism. Febrile mucocutaneous syndromes (erythema multiforme, Stevens-Johnson syndrome, or to xic epidermal necrolysis) have been associated with penicillin and with sulfonamides. For the rare patient allergic to both penicillins and sulfonamides, erythromycin is recommended. Other mac rolides, such as azithromycin or clarithromycin, also should be acceptable; they have less risk of gastrointestinal tract in to lerance but increased costs. Some experts recommend secondary prophylaxis for these patients during the observation period. However, use of oral antiseptic solutions and maintenance of optimal oral health remain important compo nents of an overall health care program. Invasive disease in infants is categorized on the basis of chronologic age at onset. Early-onset disease usually occurs within the frst 24 hours of life (range, 06 days) and is characterized by signs of systemic infection, respira to ry distress, apnea, shock, pneumonia, and less often, meningitis (5%10% of cases). Late-onset disease, which typically occurs at 3 to 4 weeks of age (range, 789 days), commonly manifests as occult bacteremia or meningitis; other focal infections, such as osteomyelitis, septic arthritis, necrotizing fasciitis, pneumonia, adenitis, and cellulitis, occur less commonly. Late, late-onset disease occurs beyond 89 days of age, usually in very preterm infants requiring prolonged hospitalization. Pilus-like structures are important virulence fac to rs and potential vaccine candidates. Associated with implementation of widespread maternal intrapartum antimicrobial prophylaxis, the incidence of early-onset disease has decreased by approximately 80% to an estimated 0. The case-fatality ratio in term infants ranges from 1% to 3% but is higher in preterm neonates (20% for early-onset disease and 5% for late-onset disease). A low or an undec table maternal concentration of type-specifc serum antibody to capsular polysaccharide of the infecting strain also is a predisposing fac to r. Other risk fac to rs are intrauterine fetal moni to ring and maternal age younger than 20 years. Black race is an independent risk fac to r for both early-onset and late-onset disease. Although the incidence of early onset disease has declined in all racial groups since the 1900s, rates consistently have been higher among black infants (0. The period of communicability is unknown but can extend throughout the duration of colonization or disease. Infants can remain colonized for sev eral months after birth and after treatment for systemic infection. For ampi cillin, the recommended dosage for infants with meningitis 7 days of age or younger is 200 to 300 mg/kg per day, intravenously, in 3 divided doses; the recommended dosage for infants older than 7 days of age is 300 mg/kg per day, intravenously, in 4 divided doses. Additional lumbar punctures and diagnostic imaging studies are indicated if response to therapy is in doubt, neurologic abnor malities persist, or focal neurologic defcits occur. For infants with uncomplicated meningitis, 14 days of treatment is satisfac to ry, but longer periods of treatment may be necessary for infants with prolonged or compli cated courses. Septic arthritis or osteomyelitis requires treatment for 3 to 4 weeks; endo carditis or ventriculitis requires treatment for at least 4 weeks. Intrapartum chemoprophy laxis should be given to all pregnant women identifed as carriers of group B strep to cocci. Colonization during a previous pregnancy is not an indication for intrapartum chemoprophylaxis. Such treatment is not effective in eliminating carriage of group B strep to cocci or preventing neonatal disease. Women expected to undergo cesarean deliveries should undergo routine culture screen ing, because onset of labor or rupture of membranes can occur before the planned cesarean delivery, and in this circumstance, intrapartum antimicrobial prophylaxis is recommended. An alternative drug is intrave nous ampicillin (2 g initially, then 1 g every 4 hours until delivery). If clindamycin susceptibility testing has not been performed, intravenous vancomycin (1 g every 12 hours) should be administered. Antimicrobial therapy is appropriate only for infants with clinically suspected systemic infection. The recom mendations are intended to help clinicians promptly detect and treat cases of early onset infections. All other maternal antimicrobial agents or durations before delivery are considered inadequate for purposes of neonatal management. Routine cultures to determine whether infants are colonized with group B strep to cocci are not recommended. Cohorting of ill and colonized infants and use of contact precau tions during an outbreak are recommended. Other methods of control (eg, treatment of asymp to matic carriers with penicillin) are ineffective. The princi pal clinical syndromes of groups C and G strep to cocci are septicemia, upper and lower respira to ry tract infections, skin and soft tissue infections, septic arthritis, meningitis with a parameningeal focus, brain abscess, and endocarditis with various clinical manifestations. Viridans strep to cocci are the most common cause of bacterial endocarditis in children, especially children with congenital or valvular heart disease, and these organisms have become a common cause of bacteremia in neutropenic patients with cancer. Among the viridans strep to cocci, organisms from the Strep to coccus anginosus group often cause localized infections, such as brain or dental abscess or abscesses in other sites, including lymph nodes, liver, and lung. Enterococci are associated with bacteremia in neonates and bacteremia, device-associated infections, intra-abdominal abscesses, and urinary tract infections in older children and adults. Among gram-positive organisms that are catalase negative and display chains by Gram stain, the genera associated most often with human disease are Strep to coccus and Enterococcus. Members of the Strep to coccus genus that are beta-hemolytic on blood agar plates include Strep to coccus pyogenes (see Group A Strep to coccal Infections, p 668), Strep to coccus agalactiae (see Group B Strep to coccal Infections, p 680) and groups C and G strep to cocci. S agalactiae subspecies equisimilis is the group C species most often associated with human infections. The anginosus group (S anginosus, Strep to coccus constellatus, and Strep to coccus intermedius) can have variable hemolysis, and approximately one third possess group A, C, F, or G antigens. Nutritionally variant strep to cocci, once thought to be viridans strep to cocci, now are classifed in the genera Abiotrophia and Granulicatella. The genus Enterococcus (previously included with Lancefeld group D strep to cocci) contains at least 18 species, with Enterococcus faecalis and Enterococcus faecium accounting for most human enterococcal infections. Outbreaks and nosocomial spread in associa tion with Enterococcus gallinarum also have occurred occasionally. Nonenterococcal group D strep to cocci include Strep to coccus bovis and Strep to coccus equinus, both members of the bovis group.

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He rarely uses speech to bacteria h pylori discount stromectol 3mg communicate infection resistant to antibiotics discount 3 mg stromectol free shipping, and his parents state that he has never done so antibiotic treatment for cellulitis order 3 mg stromectol overnight delivery. Physical examination indicates that his head is of normal circum ference and his gait is normal 700 bacteria in breast milk discount stromectol 3mg amex. A 15-year-old boy is arrested for shooting the owner of the conve nience s to re he tried to rob. He has been in department of youth services cus to dy several times for a variety of crimes against property, possession of illegal substances, and assault and battery. He is cheerful and unconcerned during the arrest, more worried about losing his leather jacket than about the fate of the man he has injured. Symp to ms must be present in two or more settings (in this case, home and school) and must cause significant impairment. During this time, age-appropriate skills such as verbal and nonverbal communication, social relationships, bowel and bladder control, and play all develop normally. The disease manifests itself as a clinically significant loss of previously acquired skills before the age of 10. In Rett disorder, the onset of the disease occurs earlier, usually 6 months after birth, and there are characteristic hand stereotypies that do not occur in childhood disintegrative disorder. The presence of the apparently nor mal development of speech and other behaviors, followed by the loss of these, distinguishes this disorder from autism, Asperger disorder, and per vasive developmental disorder, where there is no loss of previously acquired skills. When a reading disorder is caused by a defect in visual or hearing acuity, it is excluded by diagnostic criteria from being a developmental reading disorder. Almost all patients with this prob lem have spelling difficulties, and nearly all have verbal language defects. The child in 82 Disorders of Childhood and Adolescence Answers 83 this question is able to read and attend school; thus, he cannot have perva sive developmental disorder. His ability to write s to ries and communicate primarily clearly and his normal mo to r skills rule out the other diagnoses listed. Important in the evaluation of these children is an assessment of the stability and supportiveness of the home environment, and the care givers competence in taking care of the adolescent. These fac to rs will figure in to a clinicians decision as to whether a potentially suicidal adolescent must be admitted to an inpatient unit or may be released home to be closely moni to red. Fetal alcohol syndrome is characterized by intrauterine growth retardation and persistent postnatal poor growth, microcephaly, developmental delays, attentional deficits, learning disabilities, and hyper activity. Characteristic facial features are microphthalmia with short palpe bral fissures, midface hypoplasia, thin upper lip, and a smooth and/or long philtrum. Children whose mothers used opiates during pregnancy are born passively addicted to the drugs and exhibit withdrawal symp to ms in the first days and weeks of life. During the first year of life, these infants show poor mo to r coordination, hyperactivity, and inattention. These problems persist during school-age years, although few differences in cognitive per formance are reported. Infants exposed to cannabis prenatally present with decreased visual responsiveness, tremor, increased startle reflex, and dis rupted sleep patterns. Prenatal exposure to cocaine causes impaired startle 84 Psychiatry response; impaired habituation, recognition, and reactivity to novel stimuli; and increased irritability in infants. Older children present with language delays, poor mo to r coordination, hyperactivity, and attentional deficits. Nocturnal enure sis is not diagnosed before age 5, an age at which continence is usually expected. Nocturnal enure sis usually is diagnosed in childhood, although adolescent onset does occur. The treatment of choice for enuresis is the use of classic condition ing with a bell (or buzzer) and a pad. This is generally the most effective treatment, with success in over 50% of all cases. Bladder training, while sometimes effective, is decidedly less so than the bell and pad. Likewise, psychotherapy has not been shown to be effective in treating this disorder, though it may be helpful in dealing with the emotional difficulties that arise secondary to the disorder. Pharmacological treatment of this disorder includes neurolep tics and fi2 agonists (clonidine, guanfacine). Tics, while a less frequent complication of stimulant treatment, can cause significant impairment. Leukopenia, hepatitis, and cardiac arrhythmias are not associated with stimulant treatment. The distress often leads to school refusal, Disorders of Childhood and Adolescence Answers 85 refusal to sleep alone, multiple somatic symp to ms, and complaints when the child is separated from loved ones, and at times may be associated with full-blown panic attacks. The child is typically afraid that harm will come either to loved ones or to him or herself during the time of separation. This is normal behavior in children 1 to 3 years old, after which it is thought to be pathological. The caregivers motive is to vicariously receive care and attention from health providers through the sick child. The severity of the disorder varies from cases in which symp to ms are completely fabricated to cases in which the mother causes serious physical harm to or even the death of the child. Mothers in cases of Munchausen by proxy are extremely attentive to their children and often are considered model parents. These mothers are not cognitively impaired or psychotic; on the contrary, they are often quite accomplished and knowledgeable and frequently work or have worked in the medical field. A very pathological relationship develops between the mother and the victimized child, to the point that older children often collude with the mother in producing the symp to ms. When caregivers consistently disre gard the childs physical or emotional needs, the child fails to develop a secure and stable attachment with them. This failure causes a severe dis turbance of the childs ability to relate to others, manifested in a variety of behavioral and interpersonal problems. Some children are fearful, inhib ited, withdrawn, and apathetic; others are aggressive, disruptive, and dis organized, with low frustration to lerance and poor affect modulation. Some children speak only with their parents and siblings and are mute with relatives and friends. Children with selective mutism do not have a language impediment, nor do they display the lack of social interactions, lack of imagination, and 86 Psychiatry stereotyped behavior characteristic of autism. On the contrary, they can be quite interactive and communicative in a nonverbal way, using drawing, writing, and pan to mime. Children with school phobia refuse to go to school but do not have problems communicating through language. Oppo sitional defiant disorder is characterized by persistent refusal to follow rules and defiance to ward authorities, not by failure to speak. Although specific treatment for this disorder is sel dom required, in rare cases it is necessary. Diazepam (Valium) in small doses at bedtime improves the condition and sometimes completely elimi nates the attacks. The incidence is considerably higher among children with neurological or medical illnesses. The diagnosis can be difficult because younger childrens symp to ms differ from the symp to ms of depression usually displayed by adults. Often, aggression and irritability replace sad affect, and poor school functioning or refusal to go to school may be the prominent manifestations. Psychotic symp to ms are present in one-third of the cases of childhood major depression. Asking a child about suicidal ideation does not increase the risk of the child acting on this wish. The presence of the symp to ms, including being angry, spiteful and vindictive, losing his temper quickly, and deliberately annoying others, for at least 6 months is characteristic of the disease. It is also characteristic that the boy denies that he has a problem, blaming it instead on others. While sometimes the behavior starts outside the home, other times, as in this question, the disorder starts at home and then is car ried to school and other arenas.

Right to virus e68 order stromectol 3 mg visa privacy Conditions for examination and treatment should be created to zombie infection android order stromectol 3mg with mastercard ensure privacy antibiotics for acne tetralysal trusted 3mg stromectol. Only people whose involvement is necessary in order to antibiotics for dogs clavamox order stromectol 3 mg on-line deliver medical care should be present during exams and treatment. In the case of a charge filed with the police or other authorities, relevant information from the exam will need to be conveyed. Confidentiality It is critical that field staff ensure strict confidentiality about any specific incidents of sexual or gender-based violence. The possible consequences of inadequate confidentiality about these issues include the stigmatization of victims, violent revenge against those 192 I the Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies 4 committing the violent acts, and the reluctance of other victims to seek assistance. The role of the health sec to r, in collaboration with other assistance mechanisms, is to reach out to and identify survivors, provide examinations and treatment, collect medical evidence, document as appropriate, and refer to other needed care. At a minimum, care should include treatment and referral for complications of the effects of the sexual violence, including wounds, treatment or prevention of sexually transmitted infections, emergency contraception, counselling, referral to social services and psychological counselling and support services, as well as documentation and basic moni to ring and evaluation. When the situation becomes more stable, pro to cols for rape management should be established, and provision of services should be coordinated with more development oriented activities, such as skills training and income generation for survivors. Moni to ring and evaluation of gender-based violence programmes in the health sec to r Moni to ring and Evaluation (M&E) is an important process to meet the requirements of donors and other stakeholders and to maximize efficient and effective use of limited resources. In order to moni to r progress and evaluate whether a programme has achieved the intended results, data must be gathered. Moni to ring Regular moni to ring is necessary for reviewing the progress of a gender-based violence programme activity in reaching the set objectives, as well as analyzing the prevention of sexual violence and response to incidents. Various to ols, such as clinic registers, forms, and internal reports, may be used for both moni to ring and programme management (especially supervision and decision-making). The involved sec to rs, frequency and methods used for moni to ring should be decided by an established, multi-sec to ral gender based violence working group. For example, when a programme is established, you can expect to have increased reporting, but this does not mean there is more violence. The goal of such a programme is to encourage higher reporting and, therefore, better treatment and identification. Possible indica to rs include: fi Incidence of sexual violence; Moni to r the number of cases of sexual violence reported to health services, protection and security officers; fi Supplies for universal precautions; Moni to r the availability of supplies for universal precautions, such as gloves, protective clothing and disposal of sharp objects; fi Estimate of condom coverage Calculate the number of condoms available for distribution to the population; Public health guide for emergencies I 193 4 fi Estimate of coverage of clean delivery kits Calculate the number of clean delivery kits available to cover the estimated births in a 71 given period of time. Table 4-17: Indica to rs for moni to ring gender-based violence messages disseminated through drama, community dialogues, etc. Performance indica to r Measure Number of sensitization Number of drama shows depicting manifestations of gender sessions /dissemination based violence and its effects that were conducted during the activities conducted during reporting period in settlements (Programme Coordina to rs to the quarter through drama, identify technically skilled persons to encourage the social community dialogue, forums to develop drama scripts that communicate gender-based impromptu discussions and violence messages effectively. The drama scripts will focus on 4 booklet clubs types of gender-based violence, incidents and referral. Evaluation Most programmes to prevent and respond to gender-based violence in peaceful and emergency settings have not been appropriately evaluated. This increases the likelihood that resources will be wasted and unsuccessful programmes replicated, with potential harm to intended beneficiaries. While evaluations are discussed in more detail in the management chapter of this book, it is important to look at a few specific items in evaluations as they relate to gender-based violence programmes. The table below outlines some sample questions for various gender-based violence issues that need to be evaluated. Table 4-18: Sample questions for various gender-based violence issues Issues Sample questions Coordination fi What multi-sec to r and interagency procedures, practices and reporting forms are in place in the current emergencyfi Do regular working group meetings include local community groups, local advocacy groups, local government or authoritiesfi Water and sanitation fi Are there adequate numbers of latrines for each sex in the communityfi Shelter, site planning, non fi Is there a community-based plan for providing safe shelter for food items victims/survivorsfi Health and community fi Are victims of sexual violence receiving timely and services appropriate carefi Evidence-based evaluation In many situations, the absence of quantitative generalisable baseline data impedes the ability of service providers to plan for, obtain funding for, and implement essential health and psychosocial services for sexual violence survivors. Given the sheer magnitude and range of problems competing for gender-based violence funding and programmes in many countries, quantitative data can be essential to ensure that limited resources are directed to wards the physical and mental needs of women who have experienced rape and sexual violence, as well as other forms of gender-based violence. The findings of population-based assessments of gender-based violence have wide-ranging implications, including: 1) determining patterns of sexual violence; 2) establishing womens health needs and service gaps; 3) forming policy recommendations regarding the physical and mental health needs of affected women; 4) promoting advocacy using data to discuss the extent of the problem and the needs; and 5) adequately implementing programmes to address identified needs. An evidence-based survey can be applied to any situation (conflict or post-conflict) and any country. The evidence-based needs depend on the situation (internally displaced Public health guide for emergencies I 195 4 person, refugee, host population, etc. The goals of a quantitative study are to credibly document the full scope of abuses and to understand patterns and predic to rs of abuse. Good quantitative work often reveals previously hidden patterns and underlying issues and can identify targets for intervention. If done properly, the findings can be generalized to larger populations, which case documentation does not permit. Solid quantitative research also can be a source of future leads for case documentation efforts and provide essential information for programme planning and funding requirements. In Sierra Leone, numbers around the issues of rape and sexual violence during the 10-year civil conflict in Sierra Leone permitted activists to assert that each s to ry is but one of the more than 64,000 women who experienced such sexual violations. They go door- to -door and hold group discussions, community dialogues, and booklet clubs. Performed in English, French and Swahili, the plays are dramatic reflections of current circumstances. For example, one play depicted the theme of early marriage through a true s to ry about a 14-year-old girl whose parents allowed a 65-year-old man to kidnap and force her in to marriage in exchange for money. Unfortunately, you will note that note that Red Cross/Red Crescent National Society or other humanitarian staff can sometimes be the victims of sexual violence, but can also be the perpetra to rs of sexual violence. Refugee settlements can be unsafe and women may be forced to use sex as a means of securing food, shelter, and protection. The following are a few examples of sexual violence that has occurred in disaster settings: fi Sexual violence increases during crisis. In East Timor, 23% of women reported sexual violence by men outside their family during the crisis period. After the crisis, that rate dropped to 10%; fi A survey of rape survivors in South Kivu region revealed that ninety-one percent suffered from one or several rape-related illnesses citing International Alert Report; fi Up to 40% of women were raped during Liberias 14-year civil war; teenagers were the most targeted group; fi Half of rape survivors in northeast Uganda reported subsequent gynaecological problems, including chronic pelvic pain, abnormal vaginal discharge, infertility, vaginal and perineal tears, and fistula. Table 4-19: Types of sexual violence Phase Type of violence During conflict, prior to fi Abuse by those in power flight fi Sexual bartering of women fi Sexual violence and coercion by soldiers, rebels, fighters During flight fi Sexual attack and/or coercion by bandits, border guards, pirates fi Capture for trafficking by smugglers, slave traders fi Capture by combatants for sexual slavery In the country of asylum fi Sexual attack, ex to rtion by persons in authority fi Sexual abuse of fostered girls fi Sexual attack when collecting water, wood, etc. Especially where abortion services are not available, post abortion care services should be available as part of the health services available in refugee camps. In 1998 and 1999, more than 200 ethnic Burmese women and girls (averaging approximately 18-20 per month) at the Mae Tao Clinic in Thailand required treatment for abortion complications, including haemorrhage and infection. Munima aged 25 sitting on the remains of her house which was completely destroyed by the flood. Pho to : Jenny Matthews/British Red Cross Public health guide for emergencies I 199 5 Emergency mental health and psycho-social support Description this chapter intends to serve as a guide for setting up mental health and psychosocial programmes for vulnerable populations in developing countries who are or have been exposed to crisis events. It describes the psychological problems of people exposed to violence, disaster or critical incidents and provides guidelines for planning emergency mental health programmes. Learning objectives fi To discuss the mental and emotional impact of exposure to disasters; fi To define what mental health programmes can contribute to an emergency response effort; fi To design the building blocks of a mental health care programme; fi To recognise the important fac to rs for establishing long-lasting mental health programmes. Key competencies fi To recognise the mental health problems and psycho-social suffering caused by disasters, displacement, social unrest and violence; fi To apply standard guidelines when designing, implementing or evaluating an emergency mental health programme; fi To recognise the fac to rs that are important for establishing long-lasting mental health programmes. But people with good mental health have the following qualities in common: fi Being able to understand and respond to the challenges of day- to -day life. Many fac to rs, which could be biological or environmental, contribute to having good mental health. People are frequently exposed to positive as well as negative fac to rs in their everyday life. Mental health problems occur when the stress from negative fac to rs, such as pressure from work, illness or death in the family, or lack of income, greatly exceeds normal levels, or the exposure to these negative fac to rs lasts for a long period of time. Living conditions may become in to lerable, and even the most basic needs may be lacking. These conditions, along with an uncertain future and a constant state of insecurity, put great stress on families and communities. Prolonged stress can break some people down emotionally and mentally, leading to mental health problems. These problems may exhibit themselves physically (fatigue, headache, back pains), emotionally (fear, anxiety, mood changes), or through major changes in behaviour (domestic violence, alcohol abuse).

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It argues that decent work is imperative for the alleviation of poverty antibiotic 2012 order stromectol on line amex, inequality and the burden of care responsibilities antibiotic resistance health care 3mg stromectol amex. The article concludes that high unemployment and a growing informal sec to antibiotic yogurt interaction order stromectol with amex r has contributed to antibiotic yellow tablet purchase stromectol master card the expolitationof workers and unacceptable working condirions resulting in amongst other problems high youth unemployment and gender inequalities. This doc to ral thesis examines what employers and the state are currently doing to assist employees with the combination of work and care in South Africa. The study of employer involvement in work-care integration analyses the adoption of work-care arrangements in South African organisations. Overall, the study points to low levels of adoption of work-care arrangements by South African employers and evidence that employers in South Africa are not going beyond legislative minima in the provision of work-care arrangements. Based on the findings of the study and an investigation on state involvement in work-care integration in South Africa, the thesis provides recommendations for regula to ry reform in the area of work care integration and addresses potential work-care policy rationales for South Africa. This article considers the leave entitlements afforded to working fathers in South Africa, benchmarks these against international obligations endorsed by the South African government and advocates changes to South African legislation. The paper argues for a revision of South African legislation to support working fathers family care roles. This Chapter considers the requirements relating to citizenship that attach to receipt of the child support grant in South Africa. Maternity leave (Permiso y prestacion por maternidad) (responsibility of the Ministry of Labour and Social Security) Length of leave (before and after birth) fi Sixteen weeks: six weeks are obliga to ry and must be taken following the birth, while the remaining ten weeks can be taken before or after birth. By consolidating an entitlement to reduced working hours, mothers can in practice extend Maternity leave by two to four weeks (see 1e permiso de lactancia, originally to support breastfeeding). Women under 21 years do not need any previous period of social security contribution, and women between 21 and 26 only 90 days, in the last previous seven years, or 180 days during working life. On the other hand self-employed mothers are exempted from paying social security contributions while on Maternity leave. Leave can be completely transferred or partly transferred, so both parents share full or part-time leave simultaneously. If this is not possible or cannot be reasonably required, the working contract or activity has to be interrupted, and leave can be taken with payment of 100 per cent of earnings. Such leave correspondingly lasts until the beginning of Maternity leave or until the baby reaches the age of nine months. Paternity leave (permiso de paternidad, permiso por nacimien to ) (responsibility of the Ministry of Labour and Immigration) Length of leave (before and after birth) fi Fifteen calendar days. Payment and funding fi One hundred per cent of earnings, paid by the Social Security Fund with the same ceiling as for Maternity leave. Fathers who need to travel in their work have two extra days, paid by the employer (this does not apply in the public sec to r). This does not apply in the public sec to r, where the 15 days are considered as a whole, to be taken at birth time as general rule (except when the specific regional government (Comunidades Au to nomas) or institution regulates differently). Regional or local variations in leave policy fi A number of regional governments have improved entitlements. For example, public sec to r workers in Catalonia receive five days at birth (as birth leave), and a month of Paternity leave that has to be taken at the end of Maternity leave. Parental leave (Excedencia por cuidado de hijos) (responsibility ofthe Ministry of Employment and Social Security) Length of leave (before and after birth) fi Each parent is entitled to take leave until three years after childbirth. During the first year, return to the same job position is protected; after the first year, job protection is restricted to a job of the same category. Workers taking leave are credited with social security contributions, which affect pension accounts, health cover and new Maternity or Paternity leave entitlements, for the first two years in the private sec to r and for the whole period in the public sec to r. Flexibility in use fi There are no limits to the number of periods of leave that can be taken until the child is three years, with no minimum period. However, these benefits have been reduced or abolished since 2009 as a consequence of the fiscal crisis. Childcare leave or career breaks fi Unpaid career breaks are recognised in the labour and public employees regulations (excedencia voluntaria). The only protection offered is to be able to claim the right of return to an equivalent job before the end of the leave, once there is a vacancy. Other employment-related measures Adoption leave and pay fi the same regulations as for other parents for the adoption or fostering of children under six years or children with additional needs. Time off for the care of dependants fi Two days leave per worker per event (permiso por enfermedad grave de un familiar) to care for a seriously ill child or for other family reasons (serious illness, hospitalisation or death of a relative to a second degree of consanguinity or affinity), paid for by the employer. For public sec to r employees this entitlement is extended to three days (five days if travelling is required) for the care of first degree relatives. The scheme is paid at 100 per cent of regula to ry basis from sickness insurance, with previous contribu to ry requirements as for Maternity and Paternity leave. This entitlement is extended to parents working part time, in which case leave must be at least equivalent to 25 per cent of full-time hours. The leave is an individual right, but only one of the parents is entitled to take leave at any one time; but parents can alternate the use of it on a monthly base. In case of divorce, when there is no agreement, the parent with legal cus to dy has the right to take this leave and if they have joint cus to dy, it is the one who makes first claim. In cases of chronic dependency, the informal carer on leave may receive a payment, between 180 and 520. The payment is claimed by the dependent relative, and its amount depends on the relatives level of dependency recognised by a public agency. Workers taking leave are credited with social security contributions, which affect pension accounts, health cover and new leave entitlements, for the first year of full-time or part-time leave. Otherwise informal 257 carers of recognised chronic dependents are credited with the equivalent of 162. Furthermore, they can work half-time for up to one month without loss of earnings in the case of a very serious illness of a first degree relative (child, partner or parent including in-laws); they can also benefit from extra flexibility in working time as do parents of children under 12 years. The period can be divided in to two half-hours or be replaced by a half-hour shortening of the normal working day; the public sec to r and many collective agreements allow the full hour shortening of the normal working day. If both parents are working, the mother can transfer this right to the father or partner. All employed mothers can consolidate this reduction in working time as full-time leave, thus in practice extending their Maternity leave between two to four weeks. Employees may decide, within their usual work schedule, the extent and period of the working time reduction. It is defined as an individual right, and there is no payment, but workers taking this part-time leave are credited with up to two years full-time social security contributions (which affect pension accounts, and new leave entitlements). Public employees can benefit from this working time reduction until the child is 12 years, and have guaranteed some working time flexibility to adapt, for example to school hours. Since 2002 public employees in Catalonia, both fathers and mothers, can reduce their working hours by a third with a 20 per cent earnings reduction or by a half with a 40 per cent earnings reduction if they have a child under six years or care for a disabled relative, they can consolidate this reduction in working time during the first year as full-time leave to extend in practice their maternity or paternity leave. Relationship between leave policy and early childhood education and care policy the maximum period of post-natal leave available in Spain is 3 years, but most of this period is unpaid; leave paid at a high rate ends after Maternity and Paternity leave (around four months after birth). Levels of attendance at formal services for children under 3 and over 3 years are above the average for the countries included in this review. Changes in policy since April 2012 (including proposals currently under discussion) In the present context of severe economic recession and public funding cutbacks in Spain, additional support to parents taking leave provided by regional governments (Au to nomous Communities) have been reduced or else income ceilings have been increased (see 1c and 1e). In Catalonia the innovative measures introduced for public sec to r employees since 2002 have been reduced in 2012 (Catalan Law 5/2012 20 with fiscal measures to reduce public expenditure). The most important is the removal of the fully paid reduction of working time for one year at the end of Maternity or Paternity leave; this measure had had equal and very high take-up rates amongst male and female public employees, who could choose between extending Maternity or Paternity leave 16 weeks or reducing working time by a third until the child was approximately 17 months old. In order to compensate for the loss of the former option, public employees can use this latter measure during the first year, converting it as full-time leave to extend in practice their Maternity or Paternity leave the 2007 proposal to increase Paternity leave from two to four weeks in 2011 has been postponed once again. Maternity leave Maternity leave benefit covered 67 per cent of the 471,999 births in 2011 (authors calculations based on data provided by the Social Security Institute and the Spanish Statistical Institute). Coverage is the same as the previous year, remaining stable after a long period of continuous increase (from 31 per cent in 1995) due to growing maternal employment and better coverage of atypical employment situations due to regula to ry reforms. It is worth highlighting that in the context of crisis and very high general unemployment, maternal employment does not appear to be diminishing. In 2012, an average of 5,149 women per month were on leave because of risk during pregnancy, with an average duration of 100 days: 0. Roughly the same tendency, though with much lower figures, can be observed with leave during breastfeeding because of risk since it was introduced in 2007: the number of women on leave increased from 85 per month in 2008 to 132 in the first 259 months of 2012, but decreased afterwards to a mean value for 2012 of 76, while the number of days in leave decreased from 132 to 121. Paternity leave Most fathers are eligible for Paternity leave according to the Labour Force Survey data.

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