Abstract

In 1888, Adolf Fick successfully fit contact lenses, which were made from blown glass to

human. Since then, contact lenses have undergone development and revolution until this

very day. To use contact lenses, a person is required to acquire basic knowledge of handling

contact lenses. Many studies in the past are more towards the treatment and prevention of

conditions resulting from contact lens contamination and colonization by foreign organisms.

Therefore, the aim of our research is to study the effect maintenance of contact lenses

towards users’ health. The medium of our research are survey conducted towards identified

UTP student who are using contact lenses. The results of our survey found that a number of

respondents did not practice the proper way in maintaining their contact lenses. We

concluded that improper maintenance of contact lenses would affect users’ health. However,

due to the certain limitation, we suggest that another study in would be conducted with larger

number of respondent in future. We would also suggest that research in the future to focus

more on type of solutions used by contact lens users as we could not find any significant

evidence to prove whether or not it affect users’ health.

Contents

1. Abstract

2. Introduction

3. Literature Review

4. Methodology

5. Results

6. Discussion

7. Conclusion

8. References

9. Appendix

2. Introduction

The history of contact lens has its root back to 1508 where the idea was inspired by

Leonardo Da Vinci in his journal Codex of the eye, Manual D. He described a technique of

directly altering corneal power by submerging the eye in a bowl of water.

In 1998, an important development was the launch of the first silicone hydrogels onto the

market which has extremely high oxygen permeability with the comfort and clinical

performance of the conventional hydrogels which had been used for the previous 30 years.

A contact lens or also known simply as a contact is a corrective, cosmetic, or therapeutic

lens usually placed on the cornea of the eye. Some soft contact lenses are tinted a faint blue

to make them more visible when immersed in cleaning and storage solutions. Some

cosmetic lenses are deliberately colored to alter the appearance of the eye. Some lenses

now have a UV protection surface treatment to reduce UV damage to the eye's natural lens.

The aim of this study is to investigate whether improper maintenance of contact lenses is the

causes of infection among students in UniversitiTeknologiPetronas (UTP).

Past studies had shown that careless handling of lenses specifically during cleaning of

lenses may lead to microbial infections such as Acanthameoba. This statement had been

claimed by Devonshire, Munro, Abernethy & Clark (1993) and Khalid, Hisham, &Aabed

(2001). Therefore, we would like to study in depth whether the manner of improper cleaning

of lenses could lead to infections or not.

According to Gray, Cursons, Sherwan, &Rose (1995) and Dart (1988), infection does not

only occur on the contact lens itself but can also occur inside the lens case. As lens cases

are only use as storage of lenses, we believed many users have neglected the proper

management of the cases. Here, we would like to investigate the effects of careless

management of lens cases towards contact lens users.

Based on Khalid, Hisham, &Aabed (2001), extended wear of lenses, that is more than one

day could bring harm to the users but Dart (1988) stated in his study that the relation of

period of wearing a lens at one time and the effects on the users depends on the type of the

lenses used. A question is raised here whether prolonged use of lenses could cause harm to

the users or not. We would also investigate this variable in our study.

Our research questions are as follows:

Does improper manner of cleaning contact lenses could lead to infections?

Does careless management of contact lens cases could bring harm to the users and

how frequent should the cases be changed to avoid infections?

What is the optimal period of wearing contact lenses at one time to prevent

infections?

What are the crucial steps in maintaining contact lenses?

In our context of study we define some terms as follow.

Maintenance – ¬includes the act of handling, cleaning, rinsing and storing contact

lenses.

Type of contact lens – categorizing lenses on how long is the contact lens could be

used before disposing. In our study type of contact lenses ranging from daily, weekly,

monthly, and yearly.

Experienced users – Using contact lenses for more than three years.

3. Literature Review

With the rapid advance of technology, the usage of spectacle has been replaced by

just plastic that can be used to correct the eye defects called contact lens or also known as

contacts (Science Daily, n.d., Contact Lens). The idea of contact lens has been introduced

by Leonardo Da Vinci in the year 1508. (Heitz, RF and Enoch, J. M., 1987). Throughout the

years of development, Adolf Fick had successfully came out with the corrective lens in the

year1888 (Pearson R.M., Efron N.,1989). The contact lens made by Fick was using heavy

blown glass. After sometime in the year of 1956 Otto Wichterle invented lenses using soft

hydrophilic gels. But the most important development was the launch of the first silicone

hydrogels onto the market. These new materials encapsulated the benefits of silicone—

which has extremely high oxygen permeability—with the comfort and clinical performance of

the conventional hydrogels which had been used for the previous 30 years.

Why change to lens rather than spectacles.

Our study will mainly focus on the health risk of using contact lenses.We will study

how users manage their lenses to avoid the risk of infection, using contact lenses have been

quite a popular trend around the world as stated by a research by (Barr, 2004),It has been

estimated that 125 million people use contact lenses worldwide (2%), including 28 to 38

million in the United States and 13 million in Japan. The types of lenses used and prescribed

vary markedly among countries, with rigid lenses accounting for over 20% of currently-

prescribed lenses in Japan,the Netherlands and Germany but less than 5% in Scandinavia.

People choose to wear contact lenses often because of their appearances and practicality

(Sokol,Mier,Bloom&Asbell, 2009). Although both glasses and contact lenses have the same

purpose of usage, that is correcting eye sight, however contacts lens have a better

advantage. First and foremost, contact lens are worn right on the eye to create a natural

vision and also creates a wide range of focus compared to glasses which cause distortion as

there is distance between the eye and the glasses that result to poor peripheral or known as

side vision. Contacts lens also do not fog up unlike glasses which do so depending on the

surrounding temperature. Contacts can also match everything in the wardrobe whereas

glasses need to match only certain outfits due to the frames of the

glasses.(http://www.contactlenses.org/clsglasses)

Type of lenses

According to Cornea & Contact Lens Society of New Zealand Inc. (CCLS) (n.d.),

there are 3 types of lenses. The first one is disposable type contact lenses. Disposable

contact lenses are lenses which are designed to be replaced on a regular basis, usually

either daily, two-weekly or monthly. Daily disposable contact lenses are a great option for

people who only want to wear their contact lenses a few times per week, for example, for

sport.

The second type of lenses is the leave-in (extended wear) contact lenses. Leave-in

(extended wear) contact lenses are designed to be worn continuously for 30 days and nights

and then replaced with a new contact lens. They offer the ultimate in convenience, since

they usually don't need removing or mechanically cleaning.

The third type is gas permeable contact lenses. Gas permeable contact lenses are

usually used for the correction of moderate levels of astigmatism. They provide excellent

clarity of vision, especially in cases where the astigmatism is irregular (such as with

keratoconus).

Lenses can also be classifies by their functions (Wikipedia). Corrective contact

lenses are designed to improve vision for those with mismatch between the refractive power

of the eye and the length of the eye, leading to a refraction error. A cosmetic contact lens is

designed to change the appearance of the eye. Food and Drug Administration oh the USA

frequently calls non-corrective cosmetic contact lenses decorative contact lenses. There is

another function which is therapeutic contact lenses. Therapeutic contact lenses are usually

soft lenses and are often used in the treatment and management of non-refractive disorders

of the eye.

The construction materials of contact lenses can also be uses to classify the type of

lenses. (Wikipedia). The first contact lenses were made of glass. The second type are

lenses made from polymethyl methacrylate (PMMA or Perspex/Plexiglas). These PMMA

lenses are commonly referred to as "hard" lenses (this term is not used for other types of

contact lens). Then we have the third type, which is also rigid but were oxygen-permeable.

This type is referred to as rigid gas permeable or 'RGP' materials or lenses. There is also the

next type of contact lenses which are soft lenses. Soft lenses can be further categories into

hydrogels and silicon hydrogels.

How people usually manage their lenses.

For some reasons peoples do not follow meticulously the proper procedure for

wearing contact lenses. Due to the poor management they usually get infections because of

it. This is one of the objectives on this study, to find out how contact lens users managing

their lenses to avoid from getting infections that may lead to serious illness. A study from

Department of Ophthalmology from the New York University Medical Centre showed out of

103 participants of the study, approximately 24% do not clean their lenses and only 5% uses

saline solution as their mode of disinfections. The study also shows that majority of surveyed

either never use enzyme cleaners or only used them less than once a month. About 70% of

patients either never use rewetting drops or only uses them less than once a day. Another

study conducted by ( Matthews, SM, Spallholz, JE, Grimson, MJ , Dubielzig et. Al. 2006)

found contact lenses with covalently attached Selenium molecules have been shown to

reduce bacterial colonization without adversely affecting the cornea of a rabbit eye and

octylglucoside used as a contact lens surfactant significantly decreases bacterial adhesion.

Therefore we can see that with using suitable materials in handling our lens that would

prevent our eyes from getting infections.

Lens cases : on how often they clean it and change it.

Although it may look alike a small matter in caring of the lens but lens cases also play

such important roles in making sure the lens is clean from infections. Besides the fact that

lenses are really sensitive to their environment so the way users care for their lenses can be

one of the main reason why many of them get infections. Our study will raise the point which

is the importance of clean contact lens case. According to the study Compliance and

contamination in lens wear sponsored by Alcon, they found that 36% of contact lens user

wait up until 12 month to change their lens cases where else, 20% were reported they never

clean their lenses and the other 48% cleaned their lens cases with tap water. Another study

sponsored by Johnson & Johnson Vision Care named Making the case for daily disposable

contact lenses: patient non-compliance with storage case hygiene and replacement showed

among 787 contact lens wearers only 30% cleaned their lens case daily; and among these

wearers, 53% cleaned their case with tap water. Also, 4% replaced their case annually or

less often and 7% never cleaned or replaced their lens case. (Most eye care professionals

recommend that lens cases should be cleaned daily with fresh contact lens solution and

allowed to air dry, and lens cases should be discarded and replaced at least every 90 days.

These are some of the bad habits in wearing lenses. Normally users should not wash their

lens cases with tap water because the tap water itself contains a lot of chemical substances

which may infect the lens and contaminate the cases. Plus as the lens case main function is

to store lens and disinfect the lens with the special solution therefore users also need to pay

attention to the cleanliness of the lens cases.

Method of cleaning lenses

Now we have come to the most crucial thing in caring the lenses and this is also the

most important part in our study, on how users clean their lenses. Many cases reported that

wearers had eye problems due to contact lens is not because the lens itself it is because

wearers do not know how to clean their lenses using proper way. A study titled Compliance

and contamination in contact lens wear sponsored by Alcon eye care products producer,

revealed that 71% contact lens users put their lenses directly to the case without rubbing

and rinsing to disinfect them. 11% only rinse them and only 7% performed the recommended

way which is “rinse & rub” cleaning technique. Plus a survey sponsored by CIBA vision

named Compliance with lens care and contact lens case care and replacement surveyed

501 contacts users. The result revealed that 41% of those using multipurpose contact lens

solutions never performed the “rinse & rub” technique. 22% of them “topped off” their case

without discarding old contact lens solution and 26% never cleaned their case. New Zealand

contact lens website have put some guidelines on how to make sure lenses are clean and

safe to wear.

Never wear lenses longer than prescribed. Do not wear daily lenses while sleeping.

Do not wear your lenses overnight unless recommended by your contact lens

practitioner. Overnight wear of contact lenses increases the risk of complications.

Always wash, rinse, and dry your hands before handling lenses. Avoid pump and

moisturising soap and use lint free cotton towels and tissues.

Use only approved contact lens solutions for lubricating or wetting your lenses.

Always use fresh solutions in your lens case when disinfecting your lenses.

Never use non-sterile home-prepared saline. The use of home-prepared saline with

contact lenses has been associated with serious infections.

Contact lens storage cases can be a source of bacteria and other microbial growth.

Lens cases should be cleaned, rinsed, and allowed to air dry each time the lenses

are removed. Replace the lens case frequently. Household bleach is an excellent

disinfectant for contact lens cases but make sure the case is compatible with this and

rinse and dry the case thoroughly.

These are some of the proper way in handling the lenses to make sure that our eyes will free

from the infections, hence avoid us from getting eyes serious illness which some of them

may lead us to be blind.

Proper way of using& Side effects of lenses

For our research, we would also like to know whether the lens wearers in UTP are

practicing the proper way in caring for their lenses. According to Cornea & Contact Lens

Society of New Zealand Inc. (1999-2009) or CCLS, there are few facts that lens wearer

should acknowledge. The organization stated that different solutions should not always be

used together and not all solutions are safe for use with all lenses. They do believed in the

main principle of lens care that lens wearer should only use the lens care solutions

recommended by contact lens practitioner, and do not change brands without first consulting

contact lens practitioner. It is advisable to follow the instructions in the package inserts for

the use of contact lens solutions. This organization has listed down three essential steps in

contact lens care which are (in order) cleaning, rinsing and disinfecting. Contact lenses must

be cleaned, rinsed and disinfected whenever contact lenses are removed. Some solutions

can perform these functions but may not be as effective. The multipurpose solution is the

most popular cleaning solutionfor contact lenses; these are suitable for rinsing, disinfecting,

cleaning and storing lenses, and in most cases eliminate the need for protein removal

enzyme tablets. Every time contact lenses are removed, they must be cleaned, rinsed, and

disinfected before wearing again. Some solutions are designed to perform more than one of

these functions, but may not be as effective.

Fresh solutions should be used, and carrying cases should be boilable or capable of

withstanding pasteurization, It is obvious that boiling or pasteurisation of soft contact lenses

is preferable to making them aseptic by chemical means because of the dangers of solution

contamination. Lenses stored longer than 12 hours require cleaning, rinsing and disinfecting

again before use. However, the weak link in the chain always lies in the handling of lenses

with contaminated fingers; hence instruction in this aspect of the lens care is just as

important as in sterilization methods. Regular cleaning of soft lenses is mandatory,

especially before boiling, to prevent accretion of denatured mucus, protein, and foreign

bodies.

Contact lens wearers and eye care practitioners may rely too much upon contact lens

solutions to reduce microbial contamination. Studies by Ifejika, Borlace, Lucas, Roberts, &

Walker indicates that several multipurpose solutions and peroxide systems are not able to

adequate disinfect concentrations of bacteria. Daily cleaning of contact lenses is not always

properly performed by lens wearers. This indicates that many commercially available lens

care systems may not be adequate on their own. Use of monthly disposable lenses may

encourage less diligence in cleaning lenses. Therefore, an ideal care system needs to

eliminate the qualitative test of “rub and rinse” and substitute a more reliable method for

cleaning contact lenses.

4. Methodology

Overview.

We used a quantitative method of collective data. For that reason, we decided to use the

same method. We conducted a survey to study the effects of improper handling of contact

lenses. The survey was done by distributing questionnaires to contact lens users in UTP.

Population / Sample.

We used selective sampling in conducting the questionnaire. Only the contact lenses users

in UTP were administered the questionnaire. They were varied from foundation to post-

graduate students. We had 40 respondents to answer our questionnaires.

Location

We conducted our survey in UTP which is in Tronoh, Perak. The survey conducted was

easily carried out as we are also studying inUTP. It took us about a week to found 40

respondents. Most of the respondents were found in the UTP information resource center

and Pocket D.

Restriction / Limitations.

Our main restriction during conducting the survey was to identify the contact lens users.

There were not many students in UTP using contact lenses. They are prefer to use

spectacles rather than contact lenses. Moreover we cannot identify if the 40 respondents are

an adequate representation of contact lens users in UTP as we do not know the population

of contact lens user in UTP.

Sampling technique.

We chose to use the selective sampling method in our survey. In this method, we randomly

asked students whether they were contact lens users.

Procedures.

Firstly, we approached these students that most probably were using contact lenses. Only

then the questionnaires were given to them.

Next, respondents were being advised by us on answering the questionnaire. If the

respondent had some enquiries about the questionnaire we will assists them immediately.

The data collected will be kept confidential.

Materials

We used questionnaire as our medium to collect information on our studies. There are 2

types question open ended and multiple choice questions. Refer to Appendix A.

5. Results

Figure 1.1 showed the user’s period of using contact lenses. There were 30% users wore

contact lenses more than 3 years and less than 1 years. There were 20% wore contact

lenses for 1-2 years and 2-3 years.

Figure 1.2 above showed the percentage of respondents on their purpose of wearing contact

lenses. There were 7% wore contact lenses for cosmetic purpose, and 38% for corrective

purpose. The remaining 55% wore contact lenses for both purposes.

Figure 1.3 showed that the most likely type of lenses used was monthly by 83%, followed by

daily disposable lenses by 10%. Yearly and weekly type of lenses are 4% and 3%

respectively.

Figure 1.4 showed the users tend to change their lens case once per month by 53%, both for

yearly and others are 17%. 10 % changed their lens case every day and 3% changed it once

a week.

Figure 1.5 showed type of solution used by users to clean their lenses. 93% of respondents

used multipurpose solution, followed by normal saline by 7%.

Figure 1.6 showed the steps that are not performed by users when cleaning their lenses.

Most respondents did not rub their lenses using fingertips by 34%. 23% did not clean their

lens cases. 14% did not wash their hands. 9% did not store their lenses in the lens case and

did not replace the old solution in the case.

Figure 1.7 showed the frequency of users cleaning their lenses. 62% cleaned their lenses

once per day, followed by 21% for twice per week. The other 17% never cleaned their lens.

Figure 1.8 showed numbers of people experiencing infections. From 30 respondents 9

people had experienced infections and the other 21 people answered no.

6. Discussion

Period of using contact lenses

From Figure 1.1, there are 9 people with period of using contact lenses for less than

a year. We suggested this group uses contact lenses for cosmetic purposes and first-time

user.

For respondent with 1-2 years and 2-3 years period of contact lenses usage, these

groupschooses to continue using contact lenses as it helps overcome their eye defects.

Respondent with more than 3 years of experience are less likely to experience infections,

probably because they had ample experience in handling contact lenses.

From our surveys, we concluded that if a contact lenses experiences infection in the first

year of usage, they will probably stop from using contact lenses and this is most likely due to

inadequate information in using and maintaining contact lenses.

Purpose of using contact lenses

Figure 1.2 shows that half of the respondent in our surveys uses contact lenses for

both corrective and cosmetic purposes. The least preferred reason was to use contact

lenses for cosmetic purposes. We believe that the reasons are people actually prefer to uses

contact lenses to avoid using spectacles as it will hinder their active lifestyle as university

student. Using contact lenses also boost their self confidence. Only two respondents stated

that they use contact lenses for cosmetic purposes.

According to the USA Food and Drug Administration, using cosmetic lenses tend to cause

mild and serious complications. This is a possible explanation for the low number of contact

lenses users with eye infection.

Type of lenses

Figure 1.3 clearly indicates the most preferred type of contact lenses was the

monthly type. According to research by U.S Optometry and Optromologist, it was found that

96% of their respondent considers daily disposable contact lenses as the most hygienic,

followed by two-week type and monthly type contact lenses.

From our analysis, we believe that UTP student do want the hygienic quality for their contact

lenses. However, due to budget constraint, most of them are unable to opt for the most

hygienic which is the most expensive in long term. The cheapest option, the yearly type

contact lenses are the most not hygienic.

Frequency of Changing Lens Case

Based on Figure 1.4, 16 of our respondents changed their lens cases monthly. We

found out that manufacturers of contact lens solution provide free lens cases with their

product. Most of the solutions can only be used for only one month and students preferred to

buy a new solution monthly. Therefore, the majority of our respondents change their lens

case once they bought a new solution. We believed that the possibility of getting an infection

is lowered if they change their lens case in a short period of time rather than keep using the

same one for a long period of time. It is more hygienic to change the lens case frequently.

Three persons changed daily and one person changed weekly. When we totaled all the

three categories we have 20 respondents who change their lens cases after using them

within a month or less. Based on Figure 1.8, we found out that they were not the one who

had any experience with infections. We generalized that the contact lens users should

change their lens as frequently as possible to avoid getting any infections.

Type of Solution

As shown in Figure 1.5, 93% of our respondents used multipurpose solution to clean

rinse and keep their contact lenses compared to only 7% used normal saline. Wefound out

that most of our respondents use multipurpose solution as the solution has disinfecting

properties and it is not hassle to use. The abundant of multipurpose solution in the market

could also be one of the reasons why most of our respondents use it. We discovered that not

many people use normal saline as they the solution is not able to remove any proteins due

to lack of certain enzymes in the solution. As the result is not significant enough we could not

generalize anything from this extract but we could see that the multipurpose solution has

more functions and purposes compared to the normal saline. Whether the type of solution

affects the users,(infections) the relation is unknown. We would like to go deeper in these

criteria but due to lack of information we stop searching for the relation.

Steps That Are Not Performed

In Figure 1.6, 34% of the respondents did not rub their lens during cleaning. Two of

our researchers are contact lens user stated the act was not usually carried out because

they worried their lenses might get damaged. Some of the multipurpose solutions can be

used without performing the act of rubbing the lens. This could be the reason why majority of

the students did not rub their lenses. We found out that these respondents had not

experienced any infections. From this, we generalized that the act of rubbing the lens is not

a crucial part in cleaning the lens.

The figure shows 23% did not clean their lens cases. As we found out that most of the

students change their lens case within a month. It is because when they bought the new

solutions the manufacturer gave the free lens cases as for the user convenient to change the

lens cases. From the survey we found users that did not perform these steps are not the one

had experienced infections. Furthermore these steps are not that crucial to be performed

because it would not affect the users much. Whereas, for “wash hand” step, it is the most

crucial step in handling the lenses because it need to be clean in clean environment.

Besides that, users are not aware to wash their hands after handling some of chemical

products such as, cosmetics, perfume and hair gel. They did not know that the chemicals in

the products will infect the lenses and cause them to have serious eye infections. Based on

our survey we found that most of the users that did not wash their hands are tend to get eye

infections. The other important step in handling the lens is rinsing the lenses. Not rinsing the

lenses here means that they did not rinse the lenses on their palm before put it in the lens

cases. We consider most of the users found that this step is inconvenience for them and

time consuming. However, this step is consider the important step in handling in contact

lenses and may contribute to the infections if users ignore it. (Cornea & Contact Lens

Society of New Zealand Inc. 2009) stated that every time contact lenses are removed they

must be cleaned, rinsed and disinfected to make sure they are clean from any foreign

microorganisms that contribute to eye illness.

8. References

Cornea & Contact Lens Society of New Zealand Inc. (n.d.). Retrieved 3 July 2011 from

http://www.contactlens.org.nz/

Contact Lens Headlines,Studies find poor compliance with recommended contact lens care

http://www.contactlensheadlines.com/

Contact lens. Retrieved 3 July 2011, from http://en.wikipedia.org/wiki/Contact_lens

Dart, J.K.G. (1988).Predisposing factors in microbial keratitis:the significance of contact

lens wear, British Journal of Ophthalmology, 72, 926-930.

DevonshireP., Munro F.A., Abernethy C., &Clark B.J. (1993).Microbial contamination of

contact lens cases in the west of Scotland. British Journal of Ophthalmology, 77, 41-

45.

NiszlI.A.,&Markus M. B. (1998). Anti-Acanthamoeba activity of contact lenssolutions.

British Journal of Ophthalmology, 82,1033–1038.

GrayB.T.,Cursons R.T.M., Sherwan J.F., &Rose P.R. (1995). Acanthamoeba, bacterial,

and fungalcontamination of contact lens storage cases.British Journal of

Ophthalmology,79, 601-605.

9. Appendix A

Programme : __________________________ Gender: M / F

Year of Study : __________________________

We are first year chemical undergraduate students conducting a study for our academic

writing project. The purpose of this survey is to investigate the use and the maintenances of

contact lenses among UTP students. We would like to thank you for spending time

answering this questionnaire.

1. How long have you been using contact lenses?

a. Less than 1 year b. 1-2 years c. 2-3 years d. > 3 years

2. What is your purpose of using contact lenses?

a. Corrective b. Cosmetic c. Corrective & Cosmetic.

3. What type of lenses do you usually use?

a. Daily disposable b. Weekly c. Monthly d. Yearly.

4. How often do you wear your lenses?

a. Everyday b. Once a week c. Once a month d.

occasionally

Others:_______________

5. How often do you change your lens case?

a. Everyday b. Once a week c. Once a month d. Yearly

Others: _______________

6. What type of solution do you use for your lens case?

a. Multipurpose b. Normal saline c. Tap water d. Tap water

Others: _______________

7. Do you perform any of the following when you clean your lenses? If yes please circle

the statement(s) below.

a. Wash Hands

b. Replace the old solution in the lens case.

c. Clean the lens case.

d. Rinse the lenses.

e. Rub the lenses using your fingertips.

f. Store the lenses in their case and close it properly.

g. Other steps:___________________________

8. How many times doyou clean your lenses?

a. Once per day b. Twice per week c. Once a month d. Never.

Other: ________________

9. Do you feel comfortable using contact lenses?

a. Yes b. No. If no why? : ______________________

10. Have you ever had any infections while using your contact lenses?

a. Yes b. No. If yes please state the

infections:____________________

Thank you for your co-operation.