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p
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tr
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a
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su
b
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In
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h
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risk
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sp
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c
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a
m
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w
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tt
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fa
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larly
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wh
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c
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ss
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lep
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sis
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m
o
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g
c
a
tt
le
f
a
rm
e
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in
No
rth
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a
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rn
M
a
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sia
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c
ro
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-
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c
ti
o
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a
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stu
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wa
s
c
o
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d
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1
2
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a
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fa
rm
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ta
we
re
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ll
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c
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g
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a
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terv
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d
se
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ti
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s
p
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rm
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ris
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lu
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Th
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v
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f
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t
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o
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a
m
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g
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tt
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rm
e
rs
in
d
ica
tes
a
sig
n
ifi
c
a
n
t
o
c
c
u
p
a
ti
o
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a
l
ris
k
.
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u
t
u
re
p
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v
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n
ti
o
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p
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ra
m
s
sh
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d
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rio
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ti
z
e
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ro
m
o
ti
n
g
sa
fe
wo
rk
p
ra
c
ti
c
e
s to
m
it
i
g
a
te t
h
i
s ri
sk
.
K
ey
w
o
r
d
s
:
C
attle
f
ar
m
e
r
s
L
ep
to
s
p
ir
o
s
is
Occ
u
p
atio
n
al
h
ea
lth
R
is
k
f
ac
to
r
s
Ser
o
p
o
s
itiv
ity
T
h
is i
s
a
n
o
p
e
n
a
c
c
e
ss
a
rticle
u
n
d
e
r th
e
CC B
Y
-
SA
li
c
e
n
se
.
C
o
r
r
e
s
p
o
nd
ing
A
uth
o
r
:
Azia
h
Dau
d
Dep
ar
tm
en
t o
f
C
o
m
m
u
n
ity
M
ed
icin
e,
Sch
o
o
l
o
f
Me
d
ical
Sc
ien
ce
s
Un
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s
iti Sain
s
Ma
lay
s
ia
Hea
lth
C
am
p
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s
Ku
b
an
g
Ker
ia
n
,
1
6
1
5
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Ko
ta
B
h
ar
u
,
Kela
n
tan
,
Ma
lay
s
i
a
E
m
ail: a
ziah
k
b
@
u
s
m
.
m
y
1.
I
NT
RO
D
UCT
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O
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L
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to
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p
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s
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th
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[
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Ho
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h
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[
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[
4
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.
Ho
wev
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th
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f
ig
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b
eliev
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to
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Evaluation Warning : The document was created with Spire.PDF for Python.
I
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8
8
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6
Wo
r
k
p
r
a
ctice
s
lin
ke
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to
s
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p
o
s
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lep
to
s
p
ir
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s
is
a
mo
n
g
ca
ttle
fa
r
mer
s
in
…
(
A
z
ia
h
Da
u
d
)
1807
s
ig
n
if
ican
tly
u
n
d
er
esti
m
ated
d
u
e
to
f
ac
to
r
s
s
u
ch
as
lim
ited
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b
lic
awa
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en
ess
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o
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s
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ic
clin
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y
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p
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,
in
s
u
f
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er
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v
elo
p
e
d
s
u
r
v
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c
e
s
y
s
tem
s
[
5
]
,
[
6
]
.
I
n
Ma
lay
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ia,
lep
to
s
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tality
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ate
r
ep
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ec
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e
[
7
]
,
[
8
]
.
T
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co
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’
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r
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r
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[
9
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[
1
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.
C
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g
h
co
n
tam
in
ated
s
o
il
o
r
wate
r
.
Hu
m
an
-
to
-
h
u
m
an
t
r
an
s
m
is
s
io
n
is
ex
ce
ed
in
g
ly
r
ar
e
as
h
u
m
an
s
ar
e
i
n
cid
en
tal
h
o
s
ts
an
d
d
o
n
o
t
ty
p
ically
co
n
tr
ib
u
te
to
o
n
war
d
tr
a
n
s
m
is
s
io
n
[
1
1
]
,
[
1
2
]
.
T
h
e
d
is
ea
s
e
is
o
f
ten
ass
o
ciate
d
with
o
cc
u
p
atio
n
al
ex
p
o
s
u
r
e,
p
a
r
ticu
lar
ly
af
f
e
ctin
g
th
o
s
e
in
ag
r
ic
u
ltu
r
a
l
p
r
o
f
ess
io
n
s
.
W
o
r
k
er
s
in
th
i
s
s
ec
to
r
,
esp
ec
ially
th
o
s
e
in
clo
s
e
co
n
tact
with
liv
esto
ck
,
ar
e
r
ec
o
g
n
ized
as
b
ein
g
at
h
eig
h
ten
e
d
r
is
k
o
f
co
n
tr
ac
tin
g
lep
to
s
p
ir
o
s
is
[
1
3
]
,
[
1
4
]
.
A
s
tu
d
y
h
ig
h
lig
h
ted
t
h
at
clo
s
e
in
ter
ac
t
io
n
b
etwe
en
h
u
m
an
s
an
d
liv
e
s
to
ck
,
p
ar
ticu
lar
ly
i
n
tr
ad
itio
n
al
f
ar
m
in
g
s
y
s
tem
s
,
co
n
tr
ib
u
tes
to
s
ig
n
if
ican
t h
ea
lth
r
is
k
s
.
C
attle
f
ar
m
er
s
,
in
p
ar
ti
cu
lar
,
h
av
e
b
ee
n
id
e
n
tifie
d
as a
cr
itical
g
r
o
u
p
f
o
r
tar
g
eted
p
r
e
v
en
tiv
e
in
te
r
v
en
tio
n
s
[
1
5
]
.
T
h
e
liv
esto
ck
s
ec
to
r
p
la
y
s
a
p
iv
o
tal
r
o
le
in
Ma
lay
s
ia'
s
ec
o
n
o
m
y
,
f
u
lf
illi
n
g
d
o
m
esti
c
n
ee
d
s
f
o
r
m
ea
t,
m
ilk
,
an
d
d
air
y
p
r
o
d
u
cts
wh
ile
em
p
lo
y
in
g
r
u
r
al
co
m
m
u
n
itie
s
.
R
ec
en
t
n
atio
n
al
s
tati
s
tic
s
in
d
icate
an
in
cr
ea
s
in
g
liv
esto
ck
p
o
p
u
latio
n
,
p
ar
ticu
l
ar
ly
in
r
u
r
al
ar
ea
s
o
f
n
o
r
th
ea
s
ter
n
Ma
lay
s
ia,
u
n
d
er
s
c
o
r
i
n
g
th
e
im
p
o
r
tan
ce
o
f
ad
d
r
ess
in
g
zo
o
n
o
tic
r
is
k
s
in
t
h
is
s
ec
to
r
[
1
6
]
.
Desp
ite
th
is
,
t
h
er
e
r
em
ain
s
a
g
ap
in
u
n
d
e
r
s
tan
d
in
g
th
e
s
p
ec
if
ic
f
ac
to
r
s
co
n
tr
i
b
u
tin
g
to
lep
t
o
s
p
ir
o
s
is
tr
an
s
m
is
s
io
n
am
o
n
g
ca
t
tle
f
ar
m
er
s
,
a
g
r
o
u
p
with
d
is
tin
ct
en
v
ir
o
n
m
e
n
tal
an
d
o
cc
u
p
ati
o
n
al
ex
p
o
s
u
r
es.
T
h
is
s
tu
d
y
aim
e
d
t
o
d
eter
m
in
e
th
e
p
r
ev
alen
ce
o
f
lep
to
s
p
ir
o
s
is
s
er
o
p
o
s
itiv
ity
an
d
to
id
en
tify
th
e
r
is
k
f
ac
to
r
s
f
o
r
co
n
tr
ac
tin
g
lep
t
o
s
p
ir
o
s
is
am
o
n
g
ca
ttle f
ar
m
er
s
in
No
r
th
ea
s
ter
n
Ma
lay
s
ia.
2.
M
E
T
H
O
D
T
h
is
cr
o
s
s
-
s
ec
tio
n
al
s
tu
d
y
was
ca
r
r
ied
o
u
t
a
m
o
n
g
ca
ttle
f
a
r
m
er
s
ac
r
o
s
s
s
ix
d
is
tr
icts
in
N
o
r
th
ea
s
ter
n
Ma
lay
s
ia.
T
h
e
d
is
tr
icts
wer
e
c
h
o
s
en
th
r
o
u
g
h
s
im
p
le
r
an
d
o
m
s
am
p
lin
g
f
r
o
m
a
p
o
o
l o
f
ten
d
i
s
tr
icts
,
en
s
u
r
in
g
an
u
n
b
iased
an
d
r
e
p
r
esen
tativ
e
s
elec
tio
n
p
r
o
ce
s
s
.
A
lis
t
o
f
ca
tt
le
f
ar
m
er
s
f
r
o
m
th
ese
d
is
tr
i
cts
was
o
b
tain
ed
f
r
o
m
th
e
Dep
ar
tm
en
t
o
f
Vete
r
in
ar
y
Ser
v
ices.
Stra
tifie
d
r
an
d
o
m
s
am
p
lin
g
was
th
en
u
s
ed
to
allo
ca
te
th
e
n
u
m
b
er
o
f
f
ar
m
er
s
f
r
o
m
ea
ch
d
is
tr
ict,
en
s
u
r
in
g
p
r
o
p
o
r
tio
n
al
r
ep
r
esen
tati
o
n
ac
r
o
s
s
d
if
f
e
r
en
t r
eg
i
o
n
s
.
T
h
is
m
eth
o
d
en
s
u
r
ed
th
e
s
am
p
le
ca
p
tu
r
ed
th
e
g
eo
g
r
ap
h
ic
d
i
v
er
s
ity
o
f
ca
ttle
f
a
r
m
in
g
p
r
ac
tices
in
th
e
ar
ea
,
ef
f
ec
tiv
ely
r
ed
u
cin
g
s
elec
tio
n
b
ias.
T
h
e
s
am
p
le
s
ize
was
ca
lcu
lated
u
s
in
g
th
e
esti
m
ated
3
7
.
5
%
s
er
o
p
r
e
v
alen
ce
o
f
lep
to
s
p
ir
o
s
is
am
o
n
g
an
im
al
h
an
d
ler
s
,
r
ep
o
r
te
d
in
p
r
ev
io
u
s
s
tu
d
ies
[
1
7
]
.
C
o
n
s
id
er
i
n
g
a
p
o
ten
tial n
o
n
-
r
esp
o
n
s
e
r
a
te
o
f
3
0
%,
th
e
to
tal
s
am
p
le
s
ize
was
in
cr
ea
s
ed
to
1
2
0
to
en
s
u
r
e
s
u
f
f
icien
t
p
o
wer
f
o
r
s
tatis
tical
an
aly
s
is
.
E
lig
ib
le
p
ar
ticip
an
ts
wer
e
th
o
s
e
r
eg
is
ter
ed
with
th
e
Dep
ar
tm
en
t
o
f
Vete
r
in
ar
y
Ser
v
ice
s
an
d
h
ad
wo
r
k
e
d
as
ca
ttle
f
ar
m
er
s
f
o
r
at
least
s
ix
m
o
n
th
s
,
wh
ic
h
allo
wed
u
s
to
f
o
cu
s
o
n
ex
p
er
ien
ce
d
f
a
r
m
er
s
p
o
ten
tially
ex
p
o
s
ed
to
r
is
k
f
a
cto
r
s
o
v
er
a
l
o
n
g
er
p
er
io
d
.
Far
m
er
s
n
o
t
r
eg
is
ter
e
d
o
r
wo
r
k
in
g
less
th
an
s
ix
m
o
n
th
s
wer
e
ex
clu
d
ed
to
r
e
d
u
ce
v
ar
iab
ilit
y
in
ex
p
o
s
u
r
e
le
v
el
s
.
Par
ticip
an
ts
p
r
o
v
id
e
d
wr
itten
in
f
o
r
m
ed
c
o
n
s
en
t
b
e
f
o
r
e
th
e
s
tu
d
y
an
d
wer
e
in
ter
v
iewe
d
u
s
in
g
a
v
alid
ated
,
s
tr
u
ctu
r
e
d
q
u
esti
o
n
n
air
e
in
Ma
lay
.
T
h
e
q
u
esti
o
n
n
air
e
was
d
esig
n
ed
t
o
g
ath
er
d
ata
o
n
s
o
cio
d
em
o
g
r
ap
h
ic
in
f
o
r
m
atio
n
(
ag
e,
g
en
d
er
,
e
d
u
ca
tio
n
lev
e
l)
an
d
wo
r
k
p
r
ac
tices
(
u
s
e
o
f
p
er
s
o
n
al
p
r
o
tectiv
e
eq
u
ip
m
en
t,
ex
p
o
s
u
r
e
to
an
i
m
als
an
d
wate
r
s
o
u
r
ce
s
)
.
V
en
o
u
s
b
lo
o
d
s
am
p
les
wer
e
co
llected
f
r
o
m
ea
ch
p
ar
ticip
an
t
an
d
s
en
t
to
th
e
I
n
s
titu
te
f
o
r
Me
d
ical
R
e
s
e
ar
ch
(
I
MR)
f
o
r
an
aly
s
is
u
s
in
g
a
m
icr
o
s
co
p
ic
ag
g
lu
tin
atio
n
test
(
MA
T
)
to
d
etec
t
lep
to
s
p
ir
al
an
tib
o
d
ies.
T
h
e
MA
T
was
co
n
d
u
cted
wi
th
a
p
an
el
o
f
liv
e
lep
to
s
p
ir
es,
with
r
ef
e
r
en
ce
c
u
ltu
r
es
o
b
tain
e
d
f
r
o
m
th
e
B
io
m
ed
ical
R
esear
ch
R
o
y
al
T
r
o
p
ical
I
n
s
titu
te
i
n
Am
s
ter
d
am
an
d
I
MR.
Ag
g
l
u
tin
atio
n
was
d
ef
in
ed
as
≤
5
0
%
f
r
ee
lep
to
s
p
ir
es
(
i.e
.
,
≥
5
0
%
ag
g
l
u
tin
atio
n
)
co
m
p
ar
ed
to
th
e
co
n
t
r
o
l
well
.
A
titre
o
f
≥
1
:1
0
0
was
u
s
ed
as
th
e
lep
to
s
p
ir
o
s
is
s
er
o
p
o
s
itiv
ity
cu
t
-
o
f
f
,
in
d
icatin
g
p
ast lep
to
s
p
ir
a
ex
p
o
s
u
r
e
[
8
]
,
[
1
8
]
.
Data
wer
e
en
ter
e
d
a
n
d
an
al
y
ze
d
u
s
in
g
I
B
M
SP
SS
Ver
s
io
n
2
2
s
o
f
twar
e,
with
c
o
n
f
id
e
n
tiality
m
ain
tain
ed
th
r
o
u
g
h
o
u
t
th
e
an
aly
s
is
.
C
o
n
tin
u
o
u
s
v
ar
ia
b
les
wer
e
d
escr
ib
ed
u
s
in
g
m
ea
n
an
d
s
tan
d
ar
d
d
e
v
iatio
n
(
SD)
,
wh
ile
ca
teg
o
r
ical
v
ar
iab
les
wer
e
s
u
m
m
ar
ized
u
s
in
g
f
r
e
q
u
en
cies
an
d
p
er
ce
n
tag
es.
T
h
e
s
er
o
p
r
ev
ale
n
ce
o
f
lep
to
s
p
ir
o
s
is
was
r
ep
o
r
ted
wit
h
a
9
5
%
co
n
f
i
d
en
ce
i
n
ter
v
al
(
C
I
)
.
Un
iv
ar
iab
le
a
n
aly
s
is
was
d
o
n
e
u
s
in
g
s
im
p
le
lo
g
is
tic
r
eg
r
ess
io
n
in
o
r
d
er
to
an
aly
ze
wo
r
k
p
r
ac
tice
-
r
elate
d
r
is
k
f
ac
to
r
s
f
o
r
lep
to
s
p
ir
o
s
i
s
s
er
o
p
o
s
itiv
ity
.
All
v
ar
iab
les
th
at
s
h
o
wed
p
-
v
alu
e
<0
.
2
5
we
r
e
co
n
s
id
er
e
d
im
p
o
r
tan
t
an
d
s
ele
cted
to
b
e
f
u
r
th
er
test
ed
u
s
in
g
m
u
ltip
le
lo
g
is
tic
r
eg
r
ess
io
n
.
T
h
e
p
r
elim
in
ar
y
f
in
al
m
o
d
el
was
o
b
tain
ed
af
ter
v
ar
ia
b
le
s
elec
tio
n
u
s
in
g
Fo
r
war
d
L
ik
elih
o
o
d
R
atio
(
Fo
r
war
d
L
R
)
s
elec
tio
n
an
d
B
ac
k
war
d
L
ik
elih
o
o
d
R
atio
(
B
ac
k
war
d
L
R
)
elim
in
atio
n
m
eth
o
d
s
.
No
s
ig
n
if
ican
t
in
ter
ac
tio
n
s
o
r
m
u
ltico
llin
ea
r
ity
wer
e
o
b
s
er
v
ed
in
th
e
f
in
al
m
o
d
el.
T
h
e
Ho
s
m
er
–
L
em
esh
o
w
test
(
C
hi
-
s
q
u
ar
e
=
3
.
6
7
6
,
p
=
0
.
7
5
1
)
in
d
icate
d
th
at
t
h
e
m
o
d
el
f
it
well.
T
h
e
m
o
d
el'
s
o
v
er
all
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
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:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
4
,
Dec
em
b
er
20
25
:
1
8
06
-
1
8
13
1808
class
if
icatio
n
ac
cu
r
ac
y
was 8
0
.
0
%,
wh
ich
co
r
r
ec
tly
p
r
ed
icte
d
8
0
.
0
% o
f
t
h
e
ca
s
es.
Ad
d
itio
n
ally
,
th
e
ar
ea
u
n
d
er
th
e
R
OC
cu
r
v
e
was 0
.
8
1
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(
9
5
% C
I
: 0
.
7
3
1
,
0
.
9
0
3
)
,
r
ef
lectin
g
s
tr
o
n
g
d
is
cr
im
in
ato
r
y
ab
ilit
y
.
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
T
h
is
s
tu
d
y
ex
am
in
ed
th
e
p
r
ev
alen
ce
an
d
r
is
k
f
ac
to
r
s
o
f
lep
to
s
p
ir
o
s
is
am
o
n
g
ca
ttle
f
ar
m
er
s
in
No
r
th
ea
s
ter
n
Ma
lay
s
ia,
r
e
v
e
alin
g
s
ev
er
al
s
ig
n
if
ica
n
t
f
in
d
in
g
s
.
T
ab
le
1
p
r
esen
ts
th
e
s
o
cio
d
em
o
g
r
ap
h
ic
ch
ar
ac
ter
is
tics
o
f
th
e
r
esp
o
n
d
e
n
ts
.
All
p
ar
ticip
an
ts
wer
e
Ma
l
ay
s
,
with
a
m
ea
n
ag
e
o
f
5
0
.
5
y
ea
r
s
(
SD
=
1
4
.
9
4
)
.
T
h
e
m
ajo
r
ity
wer
e
m
ar
r
ied
(
7
8
.
3
%),
a
n
d
th
e
a
v
er
ag
e
f
a
m
ily
s
ize
was
5
.
2
m
em
b
er
s
(
SD
=
2
.
3
7
)
.
Mo
s
t
r
esp
o
n
d
en
ts
r
e
p
o
r
ted
a
m
o
n
th
l
y
in
co
m
e
o
f
less
th
an
R
M
1
0
0
0
(
6
0
.
8
%),
an
d
1
0
.
0
% h
ad
n
o
f
o
r
m
al
ed
u
ca
tio
n
.
T
ab
le
1
.
So
cio
d
em
o
g
r
ap
h
ic
c
h
ar
ac
ter
is
tics
o
f
th
e
r
esp
o
n
d
e
n
t
s
(
n
=
1
2
0
)
V
a
r
i
a
b
l
e
s
F
r
e
q
u
e
n
c
y
(
%)
M
e
a
n
(SD)
A
g
e
(
y
e
a
r
s)
5
0
.
5
(
1
4
.
9
4
)
G
e
n
d
e
r
M
a
l
e
1
0
4
(
8
6
.
7
)
F
e
mal
e
16
(
1
3
.
3
)
M
a
r
i
t
a
l
s
t
a
t
u
s
M
a
r
r
i
e
d
94
(
7
8
.
3
)
S
i
n
g
l
e
/
w
i
d
o
w
e
r
26
(
2
1
.
7
)
F
a
mi
l
y
M
e
mb
e
r
s
5
.
2
(
2
.
3
7
)
I
n
c
o
me
<
R
M
1
0
0
0
73
(
6
0
.
8
)
R
M
1
0
0
0
t
o
R
M
2
0
0
0
32
(
2
6
.
7
)
>
R
M
2
0
0
0
15
(
1
2
.
5
)
Ed
u
c
a
t
i
o
n
l
e
v
e
l
N
o
f
o
r
m
a
l
e
d
u
c
a
t
i
o
n
1
2
(
1
0
.
0
)
P
r
i
mary
sc
h
o
o
l
3
1
(
2
5
.
8
)
S
e
c
o
n
d
a
r
y
sc
h
o
o
l
7
7
(
6
4
.
2
)
T
h
e
s
er
o
p
r
ev
alen
ce
o
f
lep
to
s
p
ir
o
s
is
am
o
n
g
ca
ttle
f
ar
m
e
r
s
in
th
is
s
tu
d
y
was
r
em
ar
k
ab
ly
h
ig
h
at
7
2
.
5
%
(
9
5
%
C
I
:
6
3
.
5
,
8
0
.
1
)
.
T
h
is
p
r
ev
alen
ce
s
ig
n
if
ican
tl
y
s
u
r
p
ass
es
th
at
r
ep
o
r
ted
in
o
th
er
o
cc
u
p
atio
n
al
g
r
o
u
p
s
.
Fo
r
in
s
tan
ce
,
p
r
ev
io
u
s
s
tu
d
ies
h
av
e
d
o
cu
m
en
ted
s
er
o
p
r
ev
alen
ce
r
ates
o
f
3
2
.
6
%
am
o
n
g
o
il
p
alm
p
lan
tatio
n
wo
r
k
e
r
s
,
2
5
.
5
% a
m
o
n
g
h
o
s
p
ital staf
f
,
2
3
.
2
% a
m
o
n
g
r
u
b
b
er
estate
wo
r
k
er
s
,
an
d
1
7
.
9
% a
m
o
n
g
to
wn
clea
n
in
g
lab
o
r
e
r
s
[
1
9
]
.
Ad
d
iti
o
n
ally
,
a
s
tu
d
y
c
o
n
d
u
cted
in
Kela
n
tan
,
Ma
lay
s
ia,
id
en
tifie
d
ag
r
icu
ltu
r
e
wo
r
k
er
s
as
h
av
in
g
th
e
h
ig
h
est
p
r
ev
alen
ce
o
f
lep
to
s
p
ir
o
s
is
with
in
v
ar
io
u
s
o
cc
u
p
atio
n
al
ca
teg
o
r
ies
[
1
4
]
.
C
o
m
p
ar
ativ
el
y
,
h
ea
lth
y
p
a
d
d
y
p
la
n
ter
s
in
n
o
r
th
ea
s
ter
n
Ma
lay
s
ia
ex
h
i
b
ited
a
s
er
o
p
r
ev
alen
ce
o
f
2
4
.
2
%
u
s
in
g
th
e
s
am
e
s
er
o
lo
g
ical
test
(
MA
T
)
[
2
0
]
,
an
d
m
ilit
ar
y
r
ec
r
u
its
in
Per
u
af
ter
ju
n
g
le
tr
ain
in
g
s
h
o
wed
a
2
8
.
0
%
s
er
o
p
r
ev
alen
ce
[
2
1
]
.
A
r
ec
en
t
s
tu
d
y
b
y
Ph
ilip
an
d
Ah
m
e
d
f
o
u
n
d
th
at
a
g
r
icu
ltu
r
a
l
wo
r
k
e
r
s
,
p
ar
ticu
lar
l
y
th
o
s
e
in
liv
esto
ck
f
ar
m
in
g
,
co
n
s
is
ten
tly
s
h
o
w
h
ig
h
er
s
er
o
p
r
ev
a
len
ce
r
ates
f
o
r
lep
to
s
p
ir
o
s
is
co
m
p
ar
ed
to
o
th
e
r
o
cc
u
p
atio
n
al
g
r
o
u
p
s
ac
r
o
s
s
v
ar
io
u
s
g
eo
g
r
ap
h
ical
r
eg
io
n
s
[
6
]
.
Me
a
n
wh
ile,
a
s
tu
d
y
b
y
So
h
m
et
a
l
.
[
2
2
]
p
r
o
v
id
es
a
c
o
m
p
r
e
h
en
s
i
v
e
E
u
r
o
p
ea
n
p
er
s
p
ec
tiv
e
o
n
le
p
to
s
p
ir
o
s
is
in
ca
ttle,
h
ig
h
lig
h
tin
g
th
e
o
n
g
o
i
n
g
s
ig
n
if
ican
ce
o
f
t
h
is
zo
o
n
o
tic
d
is
ea
s
e
ac
r
o
s
s
d
if
f
er
en
t
g
eo
g
r
a
p
h
ical
r
eg
io
n
s
.
T
h
ese
f
in
d
in
g
s
in
d
icate
th
at
ca
ttle
f
ar
m
er
s
ar
e
at
two
to
th
r
ee
tim
es h
ig
h
er
r
is
k
o
f
lep
to
s
p
ir
o
s
is
co
m
p
ar
ed
to
o
t
h
er
h
ig
h
-
r
is
k
o
cc
u
p
atio
n
al
g
r
o
u
p
s
.
T
h
is
elev
ated
r
is
k
is
lik
ely
d
u
e
to
t
h
e
co
n
s
tan
t
p
r
esen
ce
o
f
ca
ttle
an
d
o
t
h
er
liv
esto
c
k
,
wh
ich
m
ain
tain
en
v
ir
o
n
m
en
tal
r
eser
v
o
ir
s
o
f
L
ep
to
s
p
ir
a
th
r
o
u
g
h
s
u
s
tain
ed
m
ictu
r
itio
n
.
3
.
1
.
Ris
k
f
a
ct
o
rs
a
s
s
o
cia
t
ed
wit
h sero
po
s
it
iv
it
y
T
ab
le
2
p
r
esen
ts
th
e
ass
o
ciatio
n
b
etwe
en
wo
r
k
p
r
ac
tice
ch
ar
ac
ter
is
tics
an
d
le
p
to
s
p
ir
o
s
is
s
er
o
p
o
s
itiv
ity
am
o
n
g
ca
ttle
f
ar
m
er
s
.
T
h
e
m
u
ltip
le
lo
g
is
tic
r
eg
r
ess
io
n
m
o
d
el
id
en
tifie
d
f
o
u
r
i
n
d
ep
e
n
d
en
t
p
r
ed
icto
r
s
o
f
in
f
ec
tio
n
r
is
k
,
u
n
d
er
s
co
r
in
g
th
e
o
cc
u
p
atio
n
al
h
az
ar
d
s
f
ac
ed
b
y
th
is
g
r
o
u
p
.
Far
m
er
s
wh
o
d
id
n
o
t
wea
r
r
u
b
b
er
g
lo
v
es d
u
r
in
g
wo
r
k
wer
e
n
ea
r
ly
f
o
u
r
tim
es
m
o
r
e
lik
ely
to
b
e
s
er
o
p
o
s
itiv
e
c
o
m
p
ar
ed
to
th
o
s
e
wh
o
co
n
s
is
ten
tly
u
s
ed
g
lo
v
es
(
AOR
=
3
.
9
6
;
9
5
%
C
I
:
1
.
1
3
–
1
3
.
9
1
;
p
=
0
.
0
3
2
)
.
L
i
k
ewise,
s
u
s
tain
in
g
h
an
d
wo
u
n
d
s
wh
ile
wo
r
k
in
g
m
ar
k
ed
ly
in
cr
e
ased
th
e
o
d
d
s
o
f
s
er
o
p
o
s
itiv
it
y
b
y
m
o
r
e
t
h
an
s
ev
en
f
o
ld
(
A
OR
=
7
.
2
6
;
9
5
%
C
I
:
2
.
6
1
–
2
0
.
1
8
;
p
<
0
.
0
0
1
)
,
wh
ile
leg
wo
u
n
d
s
co
n
f
er
r
ed
a
n
e
v
en
h
ig
h
e
r
r
is
k
(
AOR
=
8
.
5
2
;
9
5
%
C
I
:
1
.
9
8
–
3
6
.
6
6
;
p
=
0
.
0
0
4
)
.
I
n
ad
d
itio
n
,
f
ail
u
r
e
to
s
h
o
wer
im
m
ed
iately
a
f
ter
wo
r
k
was
ass
o
ciate
d
wit
h
a
s
ix
f
o
ld
h
ig
h
er
lik
elih
o
o
d
o
f
s
er
o
p
o
s
itiv
ity
(
AOR
=
6
.
0
4
;
9
5
%
C
I
:
1
.
6
9
–
2
1
.
6
2
;
p
=
0
.
0
0
6
)
.
T
h
ese
f
in
d
in
g
s
h
ig
h
lig
h
t
th
e
cr
itical
r
o
le
o
f
p
er
s
o
n
al
p
r
o
tec
tiv
e
eq
u
ip
m
en
t
a
n
d
p
o
s
t
-
wo
r
k
h
y
g
ien
e
in
in
ter
r
u
p
tin
g
ex
p
o
s
u
r
e
p
at
h
way
s
.
T
h
e
elev
ated
r
is
k
s
lin
k
ed
to
o
p
en
wo
u
n
d
s
s
u
g
g
est
th
at
L
ep
to
s
p
i
r
a
o
r
g
an
is
m
s
ca
n
r
ea
d
ily
p
en
e
tr
ate
co
m
p
r
o
m
is
ed
s
k
in
,
wh
er
ea
s
th
e
p
r
o
tectiv
e
e
f
f
ec
t
o
f
g
lo
v
es
a
n
d
im
m
ed
iat
e
b
ath
in
g
e
m
p
h
asizes
th
e
im
p
o
r
tan
ce
o
f
cr
ea
tin
g
phys
ical
an
d
b
eh
av
io
r
al
b
ar
r
ier
s
to
in
f
ec
tio
n
in
h
ig
h
-
ex
p
o
s
u
r
e
en
v
ir
o
n
m
en
ts
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Wo
r
k
p
r
a
ctice
s
lin
ke
d
to
s
ero
p
o
s
itive
lep
to
s
p
ir
o
s
is
a
mo
n
g
ca
ttle
fa
r
mer
s
in
…
(
A
z
ia
h
Da
u
d
)
1809
3
.
2
.
I
m
pli
ca
t
i
o
ns
o
f
hig
h sero
prev
a
lence
a
nd
identif
ied r
i
s
k
f
a
ct
o
rs
T
h
e
s
ig
n
if
ican
tly
h
ig
h
er
s
er
o
p
r
ev
alen
ce
o
f
lep
to
s
p
ir
o
s
is
a
m
o
n
g
ca
ttle
f
ar
m
e
r
s
co
m
p
ar
e
d
to
o
th
er
o
cc
u
p
atio
n
al
g
r
o
u
p
s
an
d
th
e
g
en
er
al
p
o
p
u
latio
n
u
n
d
er
s
co
r
es
th
e
h
eig
h
ten
ed
v
u
ln
e
r
ab
ilit
y
o
f
th
is
g
r
o
u
p
t
o
L
ep
to
s
p
ir
a
in
f
ec
tio
n
.
I
n
th
e
p
r
esen
t
s
tu
d
y
,
th
e
s
er
o
p
r
e
v
alen
c
e
o
f
7
2
.
5
%
am
o
n
g
ca
ttle
f
ar
m
er
s
was
m
ar
k
e
d
ly
h
ig
h
er
th
a
n
th
e
8
.
4
%
p
r
e
v
al
en
ce
r
ep
o
r
te
d
in
a
Ma
lay
s
ian
h
o
s
p
it
al
-
b
ased
s
u
r
v
e
y
o
f
f
eb
r
ile
p
atien
ts
[
1
4
]
,
r
ef
lectin
g
th
e
in
ten
s
e
e
n
v
ir
o
n
m
en
tal
ex
p
o
s
u
r
e
f
ac
ed
b
y
th
is
o
cc
u
p
atio
n
al
g
r
o
u
p
.
T
h
is
elev
ated
r
is
k
is
co
n
s
is
ten
t
with
ev
id
en
ce
f
r
o
m
I
n
d
ia,
wh
er
e
ag
r
icu
ltu
r
al
an
d
liv
esto
ck
wo
r
k
er
s
h
av
e
d
em
o
n
s
tr
ated
s
ig
n
if
ican
tly
h
i
g
h
er
s
er
o
p
r
e
v
al
en
ce
r
ates
th
a
n
t
h
e
g
e
n
er
al
p
o
p
u
latio
n
[
2
3
]
.
T
h
e
c
o
n
v
e
r
g
en
c
e
o
f
th
ese
f
i
n
d
in
g
s
ac
r
o
s
s
d
if
f
er
en
t
g
eo
g
r
ap
h
ic
s
ettin
g
s
h
ig
h
lig
h
ts
th
e
u
n
iv
e
r
s
al
n
atu
r
e
o
f
o
cc
u
p
atio
n
al
r
is
k
,
s
u
g
g
esti
n
g
th
at
clo
s
e
an
d
r
ep
ea
ted
c
o
n
tact
with
liv
esto
ck
an
d
co
n
tam
in
a
te
d
en
v
ir
o
n
m
en
ts
is
a
k
ey
d
r
iv
er
o
f
in
f
ec
tio
n
.
T
h
ese
r
esu
lts
r
ein
f
o
r
ce
th
e
n
ee
d
f
o
r
tar
g
eted
p
r
ev
en
tio
n
s
tr
ateg
ies,
in
clu
d
in
g
c
o
n
s
is
ten
t
u
s
e
o
f
p
er
s
o
n
al
p
r
o
tectiv
e
eq
u
ip
m
en
t,
r
o
u
ti
n
e
h
ea
lth
s
u
r
v
eillan
ce
,
a
n
d
wo
r
k
p
lace
h
y
g
ien
e
i
n
ter
v
en
tio
n
s
,
to
r
e
d
u
ce
th
e
b
u
r
d
en
o
f
lep
to
s
p
ir
o
s
is
am
o
n
g
h
i
g
h
-
r
is
k
f
ar
m
in
g
c
o
m
m
u
n
ities
.
A
n
o
tab
le
f
in
d
i
n
g
is
th
e
h
ig
h
p
r
ev
alen
ce
o
f
wo
r
k
in
g
with
w
o
u
n
d
s
am
o
n
g
ca
ttle
f
ar
m
er
s
.
Ov
er
h
alf
o
f
th
e
r
esp
o
n
d
en
ts
r
e
p
o
r
te
d
h
av
i
n
g
wo
r
k
ed
with
h
an
d
wo
u
n
d
s
,
an
d
a
q
u
ar
ter
with
leg
wo
u
n
d
s
.
T
h
e
n
at
u
r
e
o
f
ca
ttle
f
ar
m
in
g
,
in
v
o
lv
in
g
th
e
u
s
e
o
f
s
h
ar
p
e
q
u
ip
m
e
n
t
an
d
ex
p
o
s
u
r
e
to
r
o
u
g
h
en
v
ir
o
n
m
en
ts
,
p
r
ed
is
p
o
s
es
wo
r
k
er
s
to
s
u
ch
i
n
ju
r
ies.
T
h
e
s
e
wo
u
n
d
s
s
er
v
e
as
en
tr
y
p
o
i
n
ts
f
o
r
L
ep
t
o
s
p
ir
a,
as
s
u
p
p
o
r
t
ed
b
y
s
tu
d
ies
f
r
o
m
Ger
m
an
y
,
Nig
er
ia,
I
n
d
ia,
an
d
T
h
ailan
d
[
2
4
]
-
[
2
7
]
.
T
h
e
i
n
cr
ea
s
ed
o
d
d
s
o
f
s
er
o
p
o
s
itiv
ity
ass
o
ciate
d
with
wo
u
n
d
s
o
n
t
h
e
h
an
d
s
(
AOR
=
7
.
2
6
)
a
n
d
leg
s
(
AOR
=
8
.
5
2
)
h
ig
h
lig
h
t
th
e
cr
itical
r
o
le
o
f
p
h
y
s
ical
in
ju
r
ies
in
lep
to
s
p
ir
al
tr
an
s
m
is
s
io
n
.
R
ec
e
n
t
r
esear
ch
b
y
B
ier
q
u
e
et
al.
o
n
L
e
p
to
s
p
ir
a
s
u
r
v
iv
al
in
d
if
f
e
r
en
t
en
v
ir
o
n
m
en
tal
co
n
d
itio
n
s
s
u
g
g
ests
th
at
th
e
b
ac
ter
ia
ca
n
p
er
s
is
t lo
n
g
er
o
n
m
o
is
t sk
in
,
p
o
ten
tially
ex
p
lain
in
g
th
e
in
cr
ea
s
ed
r
is
k
ass
o
ciate
d
with
o
p
en
wo
u
n
d
s
[
1
0
]
.
Similar
ly
,
B
r
ad
le
y
a
n
d
L
o
c
k
ab
y
'
s
r
ev
iew
o
n
lep
to
s
p
ir
o
s
is
an
d
th
e
en
v
ir
o
n
m
en
t
f
u
r
th
e
r
u
n
d
e
r
s
co
r
es
th
e
co
m
p
le
x
in
te
r
p
lay
b
etwe
en
en
v
ir
o
n
m
en
tal
c
o
n
d
itio
n
s
an
d
d
is
ea
s
e
tr
an
s
m
is
s
io
n
,
em
p
h
asizin
g
th
e
n
ee
d
f
o
r
tar
g
ete
d
in
ter
v
e
n
tio
n
s
in
h
ig
h
-
r
is
k
s
ettin
g
s
lik
e
ca
tt
le
f
ar
m
s
[
2
]
.
F
u
r
t
h
e
r
m
o
r
e
,
t
h
e
p
r
o
t
e
c
t
i
v
e
e
f
f
e
c
t
o
f
w
e
a
r
i
n
g
r
u
b
b
e
r
g
l
o
v
es
(
A
O
R
=
3
.
9
6
)
e
m
p
h
as
i
z
es
t
h
e
im
p
o
r
t
a
n
c
e
o
f
p
e
r
s
o
n
a
l
p
r
o
t
e
ct
i
v
e
e
q
u
i
p
m
e
n
t
(
PP
E
)
i
n
m
i
t
i
g
at
i
n
g
i
n
f
e
ct
io
n
r
i
s
k
.
T
h
is
al
i
g
n
s
w
it
h
o
u
t
b
r
e
a
k
r
e
p
o
r
t
s
,
s
u
c
h
as
t
h
e
o
n
e
f
o
l
l
o
w
i
n
g
a
m
a
j
o
r
f
l
o
o
d
i
n
A
u
s
t
r
a
l
i
a
,
w
h
e
r
e
n
o
n
e
o
f
t
h
e
c
o
n
f
i
r
m
e
d
l
e
p
t
o
s
p
i
r
o
s
i
s
c
as
e
s
h
a
d
w
o
r
n
p
r
o
t
e
c
t
i
v
e
g
l
o
v
e
s
[
2
8
]
.
A
d
d
i
t
i
o
n
a
l
l
y
,
S
el
i
m
e
t
a
l
.
[
2
9
]
,
w
h
o
s
tu
d
i
e
d
b
o
v
i
n
e
L
e
p
t
o
s
p
i
r
o
s
i
s
i
n
E
g
y
p
t
,
e
m
p
h
a
s
i
z
e
d
t
h
e
i
m
p
o
r
t
a
n
c
e
o
f
p
e
r
s
o
n
a
l
p
r
o
t
e
c
t
i
v
e
e
q
u
i
p
m
e
n
t
i
n
r
e
d
u
c
i
n
g
in
f
e
c
t
i
o
n
r
is
k
a
m
o
n
g
l
i
v
es
t
o
c
k
h
a
n
d
l
e
r
s
.
S
i
m
i
la
r
l
y
,
t
h
e
s
i
g
n
i
f
ic
a
n
t
p
r
o
t
e
ct
i
v
e
e
f
f
ec
t
o
f
s
h
o
w
e
r
i
n
g
i
m
m
e
d
i
a
t
el
y
a
f
t
e
r
w
o
r
k
(
A
OR
=
6
.
0
4
)
s
u
g
g
e
s
ts
t
h
a
t
p
e
r
s
o
n
a
l
h
y
g
i
e
n
e
p
r
a
c
t
i
c
e
s
a
r
e
c
r
u
c
ia
l
in
r
e
d
u
c
i
n
g
e
n
v
i
r
o
n
m
e
n
t
a
l
c
o
n
t
a
m
i
n
a
t
i
o
n
a
n
d
p
r
e
v
e
n
t
i
n
g
b
a
c
t
e
r
i
a
l
e
n
t
r
y
t
h
r
o
u
g
h
w
o
u
n
d
s
.
A
s
t
u
d
y
o
n
L
e
p
t
o
s
p
i
r
o
s
i
s
r
is
k
f
a
c
t
o
r
s
a
n
d
m
a
n
a
g
e
m
e
n
t
c
h
a
l
l
e
n
g
es
i
n
d
e
v
e
l
o
p
i
n
g
co
u
n
t
r
i
e
s
h
i
g
h
l
i
g
h
ts
i
m
m
e
d
i
a
t
e
a
n
d
t
h
o
r
o
u
g
h
w
a
s
h
in
g
a
f
t
e
r
p
o
t
e
n
t
i
a
l
e
x
p
o
s
u
r
e
a
s
a
k
e
y
p
r
e
v
e
n
t
i
v
e
m
e
a
s
u
r
e
[
3
0
]
.
I
n
ter
esti
n
g
ly
,
h
a
n
d
wash
in
g
wi
th
s
o
ap
af
ter
wo
r
k
was
n
o
t
a
s
ig
n
if
ican
t
p
r
o
tectiv
e
f
ac
to
r
i
n
th
is
s
tu
d
y
.
T
h
is
co
n
tr
asts
with
f
in
d
in
g
s
f
r
o
m
p
alm
o
il
p
la
n
tatio
n
wo
r
k
er
s
in
Ma
lay
s
ia,
wh
er
e
h
an
d
wash
in
g
was
p
r
o
tectiv
e
[
2
3
]
.
T
h
e
d
is
cr
ep
a
n
cy
m
ay
b
e
attr
ib
u
ted
t
o
th
e
b
r
o
ad
er
ex
p
o
s
u
r
e
o
f
ca
ttle
f
ar
m
e
r
s
to
en
v
ir
o
n
m
en
tal
r
is
k
f
ac
to
r
s
b
e
y
o
n
d
th
e
h
an
d
s
,
s
u
ch
as
th
r
o
u
g
h
leg
wo
u
n
d
s
,
m
ak
in
g
h
a
n
d
wash
in
g
in
s
u
f
f
icien
t
o
n
i
ts
o
wn
.
C
o
m
p
r
eh
en
s
iv
e
h
y
g
ien
e
p
r
ac
tices,
in
clu
d
in
g
f
u
ll
-
b
o
d
y
wash
in
g
,
ap
p
ea
r
to
b
e
m
o
r
e
ef
f
ec
tiv
e
in
h
ig
h
-
ex
p
o
s
u
r
e
s
ettin
g
s
lik
e
ca
ttle f
ar
m
in
g
.
3
.
3
.
Sig
nifica
nce
a
nd
f
uture
direct
io
ns
T
h
e
h
ig
h
s
er
o
p
r
e
v
alen
ce
o
f
l
ep
to
s
p
ir
o
s
is
am
o
n
g
ca
ttle
f
ar
m
er
s
h
ig
h
lig
h
ts
an
u
r
g
en
t
p
u
b
lic
h
ea
lth
co
n
ce
r
n
.
T
h
e
im
p
licatio
n
s
o
f
t
h
ese
f
in
d
in
g
s
ex
ten
d
b
ey
o
n
d
Ma
lay
s
ia,
as
ev
id
en
ce
d
b
y
r
ec
en
t
d
ata
f
r
o
m
o
th
e
r
r
eg
io
n
s
.
Fo
r
ex
am
p
le,
th
e
g
l
o
b
al
r
elev
an
ce
o
f
th
ese
f
in
d
in
g
s
is
f
u
r
th
er
s
u
p
p
o
r
ted
b
y
B
ar
n
ab
é
et
a
l.
[
3
1
]
,
wh
o
p
r
o
v
id
e
d
n
ew
in
s
ig
h
ts
in
t
o
t
h
e
d
iag
n
o
s
is
an
d
ep
id
e
m
io
lo
g
y
o
f
b
o
v
in
e
lep
to
s
p
ir
o
s
is
in
B
r
az
il'
s
C
aa
t
in
g
a
b
io
m
e,
h
ig
h
lig
h
tin
g
th
e
n
ee
d
f
o
r
im
p
r
o
v
ed
s
u
r
v
eillan
ce
an
d
co
n
tr
o
l
m
ea
s
u
r
es
in
d
iv
er
s
e
ag
r
icu
lt
u
r
al
s
ettin
g
s
,
I
n
ad
d
itio
n
,
r
ec
en
t su
r
v
eillan
c
e
d
ata
f
r
o
m
th
e
E
u
r
o
p
ea
n
C
en
tr
e
f
o
r
Dis
ea
s
e
Pre
v
en
tio
n
a
n
d
C
o
n
tr
o
l 2
0
2
2
s
h
o
w
an
in
cr
ea
s
e
in
lep
to
s
p
ir
o
s
is
c
ases
ac
r
o
s
s
E
u
r
o
p
e,
with
o
cc
u
p
atio
n
al
ex
p
o
s
u
r
e
b
ein
g
a
s
ig
n
if
ican
t
r
is
k
f
ac
to
r
[
3
2
]
.
I
t
s
u
g
g
ests
o
n
g
o
in
g
ex
p
o
s
u
r
e
to
L
ep
to
s
p
ir
a
in
th
is
o
c
cu
p
atio
n
al
g
r
o
u
p
,
wh
ich
m
ay
r
ep
r
esen
t
r
ep
ea
ted
ex
p
o
s
u
r
e
r
ath
e
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Dec
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20
25
:
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ca
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Evaluation Warning : The document was created with Spire.PDF for Python.
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q
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RE
F
E
R
E
NC
E
S
[
1
]
D
.
A
.
H
a
a
k
e
a
n
d
P
.
N
.
L
e
v
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t
t
,
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L
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ma
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Mi
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6
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5
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5
.
[
2
]
E.
A
.
B
r
a
d
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y
a
n
d
G
.
L
o
c
k
a
b
y
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1
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.
[
3
]
W
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t
h
O
r
g
a
n
i
z
a
t
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(
W
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H
u
ma
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e
p
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r
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s
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s:
g
u
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d
a
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a
g
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o
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s,
s
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e
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r
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l
.
G
e
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e
v
a
:
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r
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l
t
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t
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l
i
n
e
]
.
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.
[
4
]
F
.
C
o
st
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.
,
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:
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5
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.
M
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.
,
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6
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N
.
P
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K
.
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me
d
,
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s
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[
7
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M
.
F
.
M
o
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d
R
a
d
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t
a
l
.
,
“
Le
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,
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8
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M
.
N
.
S
h
a
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.
,
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p
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.
[
9
]
V
.
B
a
r
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a
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a
n
,
N
.
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o
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:
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1
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