Chickenpox is a common illness among kids, particularly those under age 12. An itchy rash of spots that look like blisters can appear all over the body and may be accompanied by flu-like symptoms. Symptoms usually go away without treatment, but because the infection is very contagious, an infected child should stay home and rest until the symptoms are gone.
Chickenpox is caused by the varicella-zoster virus (VZV). Kids can be protected from VZV by getting the chickenpox (varicella) vaccine, usually between the ages of 12 to 15 months. In 2006, the Centers for Disease Control and Prevention (CDC) recommended a booster shot at 4 to 6 years old for further protection. The CDC also recommends that people 13 years of age and older who have never had chickenpox or received chickenpox vaccine get two doses of the vaccine at least 28 days apart.
A person usually has only one episode of chickenpox, but VZV can lie dormant within the body and cause a different type of skin eruption later in life called shingles (or herpes zoster). Getting the chickenpox vaccine significantly lowers your child's chances of getting chickenpox, but he or she may still develop shingles later.
Symptoms of Chickenpox
Chickenpox causes a red, itchy rash on the skin that usually appears first on the abdomen or back and face, and then spreads to almost everywhere else on the body, including the scalp, mouth, nose, ears, and genitals.
The rash begins as multiple small, red bumps that look like pimples or insect bites. They develop into thin-walled blisters filled with clear fluid, which becomes cloudy. The blister wall breaks, leaving open sores, which finally crust over to become dry, brown scabs.
Chickenpox blisters are usually less than a quarter of an inch wide, have a reddish base, and appear in bouts over 2 to 4 days. The rash may be more extensive or severe in kids who have skin disorders such as eczema.
Some kids have a fever, abdominal pain, sore throat, headache, or a vague sick feeling a day or 2 before the rash appears. These symptoms may last for a few days, and fever stays in the range of 100°–102° Fahrenheit (37.7°–38.8° Celsius), though in rare cases may be higher. Younger kids often have milder symptoms and fewer blisters than older children or adults.
Typically, chickenpox is a mild illness, but can affect some infants, teens, adults, and people with weak immune systems more severely. Some people can develop serious bacterial infections involving the skin, lungs, bones, joints, and the brain (encephalitis). Even kids with normal immune systems can occasionally develop complications, most commonly a skin infection near the blisters.
Anyone who has had chickenpox (or the chickenpox vaccine) as a child is at risk for developing shingles later in life, and up to 20% do. After an infection, VZV can remain inactive in nerve cells near the spinal cord and reactivate later as shingles, which can cause tingling, itching, or pain followed by a rash with red bumps and blisters. Shingles is sometimes treated with antiviral drugs, steroids, and pain medications, and in May 2006 the Food and Drug Administration (FDA) approved a vaccine to prevent shingles in people 60 and older.
Chickenpox is contagious from about 2 days before the rash appears and lasts until all the blisters are crusted over. A child with chickenpox should be kept out of school until all blisters have dried, usually about 1 week. If you're unsure about whether your child is ready to return to school, ask your doctor.
Chickenpox is very contagious — most kids with a sibling who's been infected will get it as well, showing symptoms about 2 weeks after the first child does. To help keep the virus from spreading, make sure your kids wash their hands frequently, particularly before eating and after using the bathroom. And keep a child with chickenpox away from unvaccinated siblings as much as possible.
People who haven't had chickenpox also can catch it from someone with shingles, but they cannot catch shingles itself. That's because shingles can only develop from a reactivation of VZV in someone who has previously had chickenpox.
Chickenpox and Pregnancy
Pregnant women and anyone with immune system problems should not be near a person with chickenpox. If a pregnant woman who hasn't had chickenpox in the past contracts it (especially in the first 20 weeks of pregnancy), the fetus is at risk for birth defects and she is at risk for more health complications than if she'd been infected when she wasn't pregnant. If she develops chickenpox just before or after the child is born, the newborn is at risk for serious health complications. There is no risk to the developing baby if the woman develops shingles during the pregnancy.
If a pregnant woman has had chickenpox before the pregnancy, the baby will be protected from infection for the first few months of life, since the mother's immunity gets passed on to the baby through the placenta and breast milk.
Those at risk for severe disease or serious complications — such as newborns whose mothers had chickenpox at the time of delivery, patients with leukemia or immune deficiencies, and kids receiving drugs that suppress the immune system — may be given varicella zoster immune globulin after exposure to chickenpox to reduce its severity.
Doctors recommend that kids receive the chickenpox vaccine when they are 12 to 15 months old and a booster shot at 4 to 6 years old. The vaccine is about 70% to 85% effective at preventing mild infection, and more than 95% effective in preventing moderate to severe forms of the infection. Although the vaccine works pretty well, some kids who are immunized still will get chickenpox. Those who do, though, will have much milder symptoms than those who haven't had the vaccine and become infected.
Healthy children who have had chickenpox do not need the vaccine — they usually have lifelong protection against the illness.
A virus causes chickenpox, so the doctor won't prescribe antibiotics. However, antibiotics may be required if the sores become infected by bacteria. This is pretty common among kids because they often scratch and pick at the blisters.
The antiviral medicine acyclovir may be prescribed for people with chickenpox who are at risk for complications. The drug, which can make the infection less severe, must be given within the first 24 hours after the rash appears. Acyclovir can have significant side effects, so it is only given when necessary. Your doctor can tell you if the medication is right for your child.
Dealing With the Discomfort of Chickenpox
You can help relieve the itchiness, fever, and discomfort of chickenpox by:
Using cool wet compresses or giving baths in cool or lukewarm water every 3 to 4 hours for the first few days. Oatmeal baths, available at the supermarket or pharmacy, can help to relieve itching. (Baths do not spread chickenpox.)
Patting (not rubbing) the body dry.
Putting calamine lotion on itchy areas (but don't use it on the face, especially near the eyes).
Giving your child foods that are cold, soft, and bland because chickenpox in the mouth may make drinking or eating difficult. Avoid feeding your child anything highly acidic or especially salty, like orange juice or pretzels.
Asking your doctor or pharmacist about pain-relieving creams to apply to sores in the genital area.
Giving your child acetaminophen regularly to help relieve pain if your child has mouth blisters.
Asking the doctor about using over-the-counter medication for itching.
Never use aspirin to reduce pain or fever in children with chickenpox because aspirin has been associated with the serious disease Reye syndrome, which can lead to liver failure and even death.
As much as possible, discourage kids from scratching. This can be difficult for them, so consider putting mittens or socks on your child's hands to prevent scratching during sleep. In addition, trim fingernails and keep them clean to help lessen the effects of scratching, including broken blisters and infection.
Most chickenpox infections require no special medical treatment. But sometimes, there are problems. Call the doctor if your child:
has fever that lasts for more than 4 days or rises above 102° Fahrenheit (38.8° Celsius)
has a severe cough or trouble breathing
has an area of rash that leaks pus (thick, discolored fluid) or becomes red, warm, swollen, or sore
has a severe headache
is unusually drowsy or has trouble waking up
has trouble looking at bright lights
has difficulty walking
seems very ill or is vomiting
has a stiff neck
Call your doctor if you think your child has chickenpox, if you have a question, or if you're concerned about a possible complication. The doctor can guide you in watching for complications and in choosing medication to relieve itching. When taking your child to the doctor, let the office know in advance that your child might have chickenpox. It's important to ensure that other kids in the office are not exposed — for some of them, a chickenpox infection could cause severe complications.
Fifth Disease or erythema Infectiosum is a common viral infection that usually affects children aged 2-12 years old during a change of weather. Once infected by it, the person will not get it again. The virus is spread though droplets when a person coughs or sneezes.
In children, this disease presents as a typical viral illness and starts with symptoms for 4-7 days.
About 17-18 days after exposure, children present with a bright red rash on their cheeks that is often followed by an irregularly raised shaped rash ( lacy looking rash) that appears on the trunk and extremities. This rash will come and go several times and may last two days to a month. This rash can be temporarily intensified by sunshine, cold, being warm, and by stress. There is usually no fever or they may run a low grade fever of less than 101 degrees.
Over 50% of exposed children will come down with the rash. Because this disease is mainly contagious during the weeks before the rash begins, a child who has a rash is no longer contagious and does not need to stay home from school.
There is concern for pregnant women or those with weak immune systems who contract Fifth Disease. These individuals should contact their health care provider.
Lice infestation on the human body (also known as pediculosis) is very common. Cases number in the hundreds of millions worldwide. Certain lice, such as body lice, can transmit diseases, such as typhus, relapsing fever, and trench fever, but most of the time having lice is more embarrassing and itchy than it is concerning as a disease. Lice die if they are away from a human's head or body for more than 2 days. Lice are 1-3 mm long (about the size of a sesame seed) and cling to the hair shaft. During the life cycle of lice, the female louse lays eggs, called nits, that attach to the hair shaft close to the scalp or body. These nits, which resemble dandruff, are attached with a gluelike, water-insoluble substance that makes them difficult to remove. After 6-10 days, the nits hatch as nymphs and become adults in 10 days. Adult lice live about 30 days on their human hosts. Three different types of lice infest people:
Head lice (Pediculus humanus capitis): Head lice are the most common. The Centers for Disease Control and Prevention (CDC) reports that 6-12 million people in the United States are infested each year with head lice.
Children aged 3-10 years in preschool, elementary school, or daycare centers are most likely to have lice.
All socioeconomic classes are affected.
Lice can appear in anyone's hair (more common in girls than boys), no matter what hair length or the person's degree of cleanliness. Lice are seen less often, however, in African Americans due to hair type. Head lice will not infect dogs, cats, or other pets.
Body lice (Pediculus humanus corporis): Body lice are seen more often in underdeveloped countries but also among the homeless population in the United States. Body lice are associated with poverty, overcrowding, and poor hygiene.
Body lice infestations occur more often when clothes are not changed or washed frequently.
Body lice live in the seams of clothing (not in the hair) where they lay their eggs but go to the body to feed—most often to the back, shoulder, and waist.
Bedbugs are related to lice. They hide among sheets and blankets and really do bite during the night when they seek a warm body for a meal. They usually leave brown or black markings on the bed linen and bite in rows, often leaving 3 or more linear bite marks.
Head lice are transmitted mainly through head-to-head contact (sharing pillows, lying on carpet, wearing someone's hat).
Head lice cannot jump or fly, so sitting near someone will not transmit lice. Indirect contact, such as with brushes and bed linens, is less likely to lead to transmission because the louse dies if away from the scalp for more than 2 days.
Body lice are transmitted by direct contact with an infected person.
Body lice are frequently seen among the homeless and others living in overcrowded conditions, where clothes are not washed often and where overall cleanliness is lacking.
Found behind the ears and near the hairline at the neck—but can be difficult to see (They can change color to match the hair.)
Nits look like whitish shells found on the hair strand near the scalp. They are firmly attached to the hair shaft and cannot be flicked off easily.
May have scalp itching, redness, and crusting or no symptoms at all.
Can result in skin infections, especially if the bites are repeatedly scratched
Infection can lead to swollen nodes that form lumps behind the ears and on the neck.
Lice and nits are found in seams of clothing.
Red, itchy bite marks may be seen on the body.
With infected scratch marks, there is increased pain, redness, swelling, or drainage.
Itching is often worse at night and in the elderly can cause insomni
Self-Care at Home
Search for head lice when hair is wet. Use a fine-toothed comb (or a louse comb), clear tape (to stick on hair to pick up nits), a magnifying glass, and a strong light.
Wet combing should be done every 2-3 days over a 2-week period, with small sections of hair, working out from the scalp. Some call this "bug busting," and it can be very effective.
If lice are found, treat with an anti-lice agent and repeat in 7-10 days to kill newly hatched nits.
How to use anti-lice agents:
Over-the-counter treatment is available and should be used first. If after 2 applications, lice are still present, then prescription anti-lice agents may be needed from your doctor. Apply the anti-lice agent to dry hair for the time listed on the product (usually 10 minutes). Shampoo and rinse hair and comb as directed with a fine-toothed comb. Repeat anti-lice treatment in 7-10 days to kill nits that may have hatched.
Nonprescription anti-lice agents include Nix Lotion (permethrin 1%) and Rid, A200, and Pronto shampoos (pyrethrin products).
Check all household members and treat only if lice or nits are seen.
If a child is younger than 2 years, comb to remove lice and nits but do not use anti-lice agents.
Hair conditioners may coat or cover the lice, so they should not be used before applying anti-lice agents.
Wash all bed linens and clothing that have been in contact with the infested person in the past 2 days. Use hot water and the hot cycle in the dryer.
Some recommend that water be at least 140°F to effectively kill the lice and nits. Most hot-water heaters are set at 120°F for child safety. This lower temperature may be effective.
All nonwashable items such as stuffed animals should be placed in plastic bags for 2 weeks then opened outdoors. Dry cleaning may be an alternative.
Disinfect combs and brushes in hot water or alcohol. Soak for more than 5 minutes in very hot water (greater than 131°F or 55°C).
Vacuum floors and furniture, especially couches and areas used by children. Throw away the vacuum bag immediately.
Herbal therapy and oil treatments have not been proven to work.
Do not use gasoline, kerosene, or oils. Burns have occurred.
Do not shave the person's head. This drastic measure is not necessary.
If lice are seen in a school-aged child, notify the school nurse or teacher in order to limit the spread.
Wash the body thoroughly.
Wash and dry all bed linens and clothes in hot cycles. Destroy what you can because these nits can survive longer without human contact.
Anti-lice agents are usually not needed if clothing is thrown away and bed linens are thoroughly washed.
Check all household members or close contacts. Treat them only if lice or nits are seen.
Vacuum floors and furniture. Throw the vacuum bag away immediately.
Chemical insecticide sprays in the home are not effective and not recommended.
Use over-the-counter antihistamines (such as diphenhydramine, Benadryl) for itching.
The conjunctiva is the thin, clear membrane over the white part of the eye; it also lines the eyelids. Inflammation of this membrane is called conjunctivitis. Its common name, pink eye, can refer to all forms of conjunctivitis, or just to its contagious forms.
Pink Eye Symptoms and Signs
The most obvious symptom of conjunctivitis is, of course, a pink eye. The pink or red color is due to inflammation. Conjunctivitis may also cause your eye to hurt or itch.
How can you tell what type of pink eye you have? The way your eyes feel will give some clues:
Viral conjunctivitis usually affects only one eye and causes excessive eye watering and a light discharge.
Bacterial conjunctivitis affects both eyes and causes a heavy discharge, sometimes greenish.
Allergic conjunctivitis affects both eyes and causes itching and redness in the eyes and sometimes the nose, as well as excessive tearing.
Giant papillary conjunctivitis (GPC) usually affects both eyes and causes contact lens intolerance, itching, a heavy discharge, tearing and red bumps on the underside of the eyelids.
To pinpoint the cause and then choose an appropriate treatment, your doctor will ask some questions, examine your eyes, and possibly collect a sample on a swab to send out for analysis. Give a careful account of the episode, because oftentimes your answers alone with reveal the diagnosis.
What Causes Pink Eye (Conjunctivitis)?
Conjunctivitis may be triggered by a virus, bacteria, an allergic reaction (to dust, pollen, smoke, fumes or chemicals) or, in the case of giant papillary conjunctivitis, a foreign body on the eye, typically a contact lens. Bacterial and viral systemic infections also may induce conjunctivitis.
Pink Eye (Conjunctivitis) Treatment
Your first line of defense is to avoid the cause of conjunctivitis. Both viral and bacterial conjunctivitis spread easily to others. Here are some tips to avoid spreading the conditions or re-infecting yourself:
Wash your hands frequently, and avoid touching or rubbing your eyes.
Don't share washcloths, towels or pillowcases with anyone else, and wash these items after each use.
Don't share eyedrops or cosmetics such as eyeliner, eye shadow or mascara. Replace them after you're healed, to avoid re-infection.
It is unlikely that you'd spread pink eye just by kissing someone! But keep in mind that having your eyes close to someone else's increases the chance of your eye fluids coming into contact with their eyes and infecting them with the bacteria or virus that caused your own pink eye.
Your eyecare practitioner may recommend that you discontinue contact lens wear during this time or replace your contact lenses after you're healed.
Warm compresses may help soothe your eyes if you have viral or bacterial conjunctivitis.
To avoid allergic conjunctivitis, keep windows and doors closed on days when the pollen is heavy. Dust and vacuum frequently to alleviate potential allergens in the home. Stay in well-ventilated areas if you're exposed to smoke, chemicals or fumes. Cold compresses can be very soothing.
If you've developed giant papillary conjunctivitis, odds are you're a contact lens wearer. You'll need to stop wearing your contact lenses, at least for a little while. Your eye doctor may also recommend that you switch to a different type of contact lens, to prevent the conjunctivitis from recurring. For example, you might need to go from soft contacts to gas permeable ones, or vice versa, or you might need to switch to a type of lens that you replace more frequently, such as from conventional contact lenses to daily disposable ones. GPC can also result from prosthetics, stitches and more. Your eye doctor will decide if removal is appropriate.
Doctors don't normally prescribe medication for viral conjunctivitis because it usually clears up on its own within a few days. Antibiotic eyedrops will alleviate bacterial conjunctivitis, whereas antihistamine allergy pills or eyedrops will help control allergic conjunctivitis symptoms. For giant papillary conjunctivitis, your doctor may prescribe eyedrops to reduce inflammation and itching.
Usually, conjunctivitis is a minor eye infection, but sometimes it can develop into a more serious condition. See your eye doctor for a diagnosis before using any eyedrops in your medicine cabinet from previous infections or eye problems.
Strep throat is an infection caused by group A streptococcus bacteria, and it's very common among kids and teens. The symptoms of strep throat include fever, stomach pain, and red, swollen tonsils.
Strep throat usually requires treatment with antibiotics. With the proper medical care - along with plenty of rest and fluids - your child should be back to school and play within a few days.
How Does Strep Throat Spread?
Anybody can get strep throat, but it's most common in school-age kids and teens. It occurs most often during the school year when big groups of kids and teens are in close quarters.
The bacteria that cause strep throat tend to hang out in the nose and throat, so normal activities like sneezing, coughing, or shaking hands can easily spread the strep infection from one person to another. That's why it's so important to teach your child the importance of hand washing - good hygiene can lessen your child's chances of getting contagious diseases like strep throat.
What's the Difference Between Strep Throat and a Sore Throat?
Not all sore throats are strep throats. Most episodes of sore throat - which can be accompanied by a runny nose, cough, hoarseness, and red eyes - are caused by viruses. Sore throats usually clear up on their own without requiring medical treatment.
If your child has strep throat, he or she will start to develop other symptoms within about 3 days. Those symptoms can include:
* red and white patches in the throat
* difficulty swallowing
* tender or swollen glands (lymph nodes) in the neck
* red and enlarged tonsils
* lower stomach pain
* general discomfort, uneasiness, or ill feeling
* loss of appetite and nausea
Diagnosing Strep Throat
If your child's throat is sore and he or she has other strep throat symptoms, it's a good idea to call your child's doctor. The doctor will likely do a rapid strep test in the office, using a cotton swab to take a sample of the fluids at the back of your child's throat. The test only takes about 5 minutes. If it's positive, your child has strep throat. If the test is negative, the doctor will send a sample to a lab for a throat culture. The results are usually available within a few days.
Treating Strep Throat
In most cases, doctors prescribe about 10 days of antibiotic medication to treat strep throat. Within about 24 hours after your child starts taking the antibiotics, his or her temperature will probably be back to normal, and your child will no longer be contagious. By the second or third day after taking antibiotics, the other symptoms should start to go away, too.
Even though your child may not feel sick at that point, it's very important that he or she finish the antibiotic prescription. If your child stops taking antibiotics too soon, bacteria can remain in the throat and the symptoms can return.
If your child is not treated for strep throat, he or she is most infectious when the symptoms are the most severe but could remain contagious for up to 21 days. Lack of treatment - or not finishing the prescribed course of antibiotics - also could put your child at risk for other health problems, such as rheumatic fever (which can cause permanent damage to the heart), scarlet fever, blood infections, or kidney disease.
To prevent your sick child from spreading strep throat to others in your home, keep his or her eating utensils, dishes, and drinking glasses separate from those that everyone else is using. Wash them in hot, soapy water after each use. Also, make sure your child doesn't share food, drinks, napkins, handkerchiefs, or towels with other family members. Make sure your child covers his or her mouth and nose during a sneeze or a cough to prevent passing infectious fluid droplets to someone else. And it's a good idea to throw out your child's toothbrush after the antibiotic treatment has been started, and your child's sickness is no longer contagious.
Caring for Your Child With Strep Throat
There's plenty you can do to help your child feel better. To prevent dehydration, make sure your child drinks plenty of cool liquids, such as water or ginger ale, especially if he or she has had a fever. Avoid orange juice, grapefruit juice, lemonade, or other acidic beverages, which may irritate your child's throat. Warm liquids like soups, sweetened tea, or hot chocolate can be soothing.
As your child starts to feel better, talk to your child's doctor about the best time to return to school and other routine activities.
West Nile virus is transmitted to humans by a mosquito bite. The virus can cause encephalitis (inflammation of the brain) or meningitis (inflammation of the lining of the brain and spinal cord).
West Nile virus was discovered in 1937 in the West Nile district of Uganda. New interest was created when West Nile emerged in the United States for the first time in the New York City area in August 1999. There were 62 confirmed human cases and 7 deaths during this outbreak, creating widespread concern.
Since the initial 1999 New York City outbreak, the cases of West Nile encephalitis have been relatively limited. In 2002, there were a total of 480 reported cases in humans and 24 deaths (as of August 28, 2002).
The distribution of the virus is spreading across the United States, as determined from surveillance of infected birds by the Centers for Disease Control and Prevention. In a little more than a year, West Nile spread to 11 states along the East Coast. In 2002, the virus spread to Florida, Arkansas, Louisiana, and Texas. Cases are also being seen in the Dakotas, Colorado, Nebraska, and Wyoming.
Whether West Nile encephalitis will present a serious health risk to the United States in the future is unknown. Using precautions directed at limiting contact by mosquitoes is the best preventive measure at this time.
West Nile Virus Causes
West Nile virus is transmitted to humans by the bite of an infected mosquito. Mosquitoes become infected by biting birds that harbor the virus. The virus is not spread from person to person or from infected birds to humans without a mosquito bite. The virus has now been found in 111 bird species and about a dozen mammals.
How West Nile virus entered New York is not entirely clear. The most likely explanation is that the virus was introduced by an imported infected bird or by an infected human returning from a country where West Nile virus is common. Before the 1999 New York outbreak, West Nile encephalitis had been identified only in Africa, Asia, the Middle East, and only rarely in Europe.
Most cases of West Nile occur during the warm weather months. Nonetheless, the mild climate in southern states is expected to sustain the mosquitoes beyond those months.
West Nile Virus Symptoms
Signs and symptoms of the West Nile virus infection range from no symptoms at all to a rapidly fatal brain infection. In areas where the virus is common, people are more likely to show no symptoms of the infection or have only a mild, flulike illness rather than a severe brain infection. Even in an area of outbreak, the likelihood of a person developing illness after infection with West Nile virus is about 1 in every 140-300 people.
West Nile virus infection typically begins with the abrupt onset of fever, chills, muscle aches, headache, and overall feeling of illness. Headache is particularly common and may be severe. The person may have sensitivity to light with pain behind the eyes.
Most people fully recover. In others, particularly the elderly, the disease can progress to cause encephalitis or meningitis.
In the 59 people hospitalized during the initial New York outbreak, signs and symptoms included fever (90%), muscle weakness (54%), headache (46%), altered mental status (44%), rash (22%), stiff neck (19%), joint aches (17%), sensitivity to light (15%), and body aches (14%).
When to Seek Medical Care
West Nile virus is transmitted only by mosquitoes during summer months and generally only appears between the months of May to October.
People who experience signs or symptoms of serious illness, and have been bitten by a mosquito in the geographic area where West Nile virus is known to appear, should see their doctor immediately.
Most people with mild symptoms of low-grade fever and muscle aches do not have West Nile virus and will not require specific diagnostic testing.
Anyone who has symptoms of severe illness such as mental status changes, high fever, neck stiffness, sensitivity to light, or confusion should go to the hospital's emergency department immediately. The West Nile encephalitis that occurred during the initial New York outbreak was especially notable for its severe muscle weakness. This is another important warning symptom.
Home care for people who suspect they may have become infected with West Nile virus is fairly limited. There is no specific treatment.
Mild illness does not require therapy other than medications to reduce fever and pain. Avoid aspirin because it presents a risk for a fatal condition known as Reye syndrome, especially in children.
There is no known effective antiviral treatment or vaccine to prevent West Nile virus.
Milder illnesses do not require treatment.
In severe cases of West Nile virus, intensive supportive therapy is indicated. This includes hospitalization, IV fluids and nutrition, airway management (some people may need a tube to keep the airway open), ventilatory support (some people may need a machine to help them breathe), prevention of secondary infections, as well as good nursing care.