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Patients hypoglycemia was associated with greater patients titrating glucose-lowering drugs should understand situations that in- risk of dementia (63) buy cheap levitra extra dosage 40 mg on-line erectile dysfunction causes in early 20s. Hypoglycemia significantly associated with subsequent patients to treat hypoglycemia with may increase the risk of harm to self or episodes of severe hypoglycemia (64) cheap levitra extra dosage 40 mg amex impotence workup. Hypoglycemia treat- use and carbohydrate intake and exer- with type 1 diabetes, found no associa- ment requires ingestionofglucose-orcar- cise are necessary, but these strategies tion between frequency of severe hypo- bohydrate-containing foods. Pure glucose awareness (or hypoglycemia-associated Severe hypoglycemia was associated is the preferred treatment, but any form of autonomic failure) can severely compro- withmortalityinparticipantsinboththe carbohydrate that contains glucose will mise stringent diabetes control and qual- standard and the intensive glycemia arms raise blood glucose. Ongoing insulin activity or insulin release, especially in older adults, and a treatment intensity were not straightfor- secretagogues may lead to recurrent hypo- diminished autonomic response, which ward. An association of severe hypoglyce- glycemia unless further food is ingested af- both are risk factors for, and caused by, mia with mortality was also found in the ter recovery. An association be- normal, the individual should be counseled cycle” is that several weeks of avoidance tween self-reported severe hypoglycemia to eat a meal or snack to prevent recurrent of hypoglycemia has been demonstrated and 5-year mortality has also been report- hypoglycemia. Hence, patients with one or more The use of glucagon is indicated for the and the elderly are noted as particularly episodes of clinically significant hypogly- treatment of hypoglycemia in people un- vulnerable to clinically significant hypo- cemia may benefit from at least short- able or unwilling to consume carbohy- glycemia because of their reduced ability term relaxation of glycemic targets. Those in close contact to recognize hypoglycemicsymptoms and with, or having custodial care of, people effectively communicate their needs. Impact reduces severe hypoglycemia in hypoglycemia- panied by ketosis, vomiting, or alteration in of self monitoring of blood glucose in the man- unaware patients with type 1 diabetes. Diabetes agement of patients with non-insulin treated Care 2013;36:4160–4162 the level of consciousness, marked hyper- diabetes: open parallel group randomised trial. Adequate fluid and 1174–1177 insulin-pump interruption for reduction of hy- caloric intake must be ensured. N Engl J Med 2013;369:224–232 dehydration is more likely to necessitate Farmer A; Diabetes Glycaemic Education and 26. Cost effectiveness of Safety of a hybrid closed-loop insulin delivery self monitoring of blood glucose in patients system in patients with type 1 diabetes. A ofbloodglucose inpatientswithtype 2diabetes clinical trial of continuous subcutaneous insulin and the hyperglycemic nonketotic hyper- mellitus who are not using insulin. Juvenile Diabetes Research Foundation Con- 28:1568–1573 in Adult Patients With Diabetes” (69). Continuous glu- Diabetes Control and Complications Trial/ cose monitoring and intensive treatment of type 1 Epidemiology of Diabetes Interventions and References diabetes. As- strong association between frequency of self- guided pump therapy in type 1 diabetes: a rand- sociation of glycaemia with macrovascular and monitoring of blood glucose and hemoglobin omised controlled trial. Frequent monitoring of A1C during nificantly reduces A1C levels in poorly con- T1D Exchange clinic registry. Diabetes Care 2008;31:1473–1478 test strips in veterans with type 2 diabetes mel- 2014;51:845–851 33. Diabe- tients who self-monitor blood glucose and their glucose monitoring on hypoglycemia in type 1 tes Care 2016;39:1462–1467 unused testing results. Choosing wisely [Internet], Continuous Glucose Monitoring Study Group, glucose concentrations in children with type 1 2013. Accessed 18 ousglucose monitoringinwell-controlledtype 1 cose determinations by sensors. Sustained benefitof betes screening with hemoglobin A1c versus fast- detemir with insulin glargine when adminis- continuous glucose monitoring on A1C, glucose ing plasma glucose in a multiethnic middle-school tered as add-on to glucose-lowering drugs in profiles, and hypoglycemia in adults with type 1 cohort. Treat-to-target trials: uses, inter- parative effectiveness and safety of methods cose in children with type 1 diabetes. Diabetes of insulin delivery and glucose monitoring for Care 2010;33:1025–1027 Obes Metab 2014;16:193–205 diabetes mellitus: a systematic review and 37. Acta Diabetol 2016;53:57–62 time continuous glucose monitoring significantly gression of diabetic retinopathy in patients with S56 Glycemic Targets Diabetes Care Volume 40, Supplement 1, January 2017 type 1 diabetes: 18 years of follow-up in the cardiovascular disease in patients with type 1 58. Diabetes Control and Complications Trial/ tes, 2015: a patient-centered approach: update Trial/Epidemiology of Diabetes Interventions Epidemiology of Diabetes Interventions and to a position statement of the American Diabe- and Complications Research Group. Diabetes Care 2001;24: sive insulin therapy prevents the progression of ventions and Complications and Pittsburgh 775–778 diabetic microvascular complications in Japa- Epidemiology of Diabetes Complications Expe- 60. Effect of intensive blood-glucose control tion between 7 years of intensive treatment of Glucose concentrations of less than 3. Lan- 2015;313:45–53 joint position statement of the American Diabe- cet 1998;352:854–865 51. Lan- Association and a scientific statement of the group of the American Diabetes Association cet 1998;352:837–853 American College of Cardiology Foundation and the Endocrine Society. Diabetes Care 2012;35:787–793 lar complications in veterans with type 2 diabe- diabetes. Intensive blood glucose con- cular outcomes in type 2 diabetes [published Musen G, et al. Long-term effect of diabetes and trolandvascularoutcomesinpatientswithtype2 correction appears in Diabetologia 2009;52: its treatment on cognitive function.

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Disposal of filter backwash is preferable unless treatment is available to provide a good quality supernatant for recycling order 60 mg levitra extra dosage free shipping erectile dysfunction diabetes uk, and the recycling is carried out over extended periods purchase levitra extra dosage 60mg with mastercard injections for erectile dysfunction treatment. Adequate treatment of filter backwash prior to recycling should not increase risk unacceptably. Supernatant from sludge treatment processes may also introduce a risk if recycled. If disposal to sewer is not possible then discharge of supernatant to receiving water if treated properly or recycling to part of a treated washwater recovery system would be preferable, so that some treatment and/or settlement is possible. For instance, a treatment works must reduce the source water concentration of Giardia by 99. The level to be achieved depends to some extent on the source water, and although an overall target for log removal of pathogens is expected to be achieved, the decision as to which treatment processes will be used to achieve this is left to the Water Service Authority. Certain types of treatment are expected to be present, and other treatment processes must be approved in order to contribute log removal ‘credits’. To claim these credits it must be demonstrable that these processes are working within normal operating parameters. Treatment upstream of disinfection is also crucial to the performance of any disinfection processes. If the bacteriological loading entering the disinfection stage is too great then disinfection will not be able to achieve the required reduction in numbers of bacteria and pathogens. In addition to this, conventional disinfection practices will require treated water to achieve certain standards in terms of turbidity, pH and Water Treatment Manual: Disinfection other parameters prior to their application. Any upstream processes must be able to prepare the water so that disinfection is not compromised, for example in relation to turbidity removal. Upstream processes can also be critical to minimise the risk from disinfection by-products. The selection of the appropriate disinfection system should be made on an individual supply by supply basis. The evaluation of particular source risk following analysis of raw water monitoring to determine the extent of pathogen removal/inactivation required of the disinfection system. The disinfection technology must be capable of removing or inactivating all pathogens potentially present in the final water. An assessment of the adequacy of contact time for chemical disinfection technologies and the necessity to ensure that minimum contact times required for disinfection are achieved. Any disinfection technology used must be capable of being verified, and that such verification is recorded, at all times as required by Regulation 13. An assessment of the requirement to ensure that a residual disinfectant is present in the distribution network for all but very small distribution networks. Where disinfection technologies achieve equally effective outcomes the water supplier should have regard to the financial implications from the capital and ongoing operational aspects to ensure that the most cost effective solution is selected. The above factors should be considered by a water supplier on a site specific basis to determine the disinfection system to be operated at each water treatment plant. While the manual discusses the commonly used and widely accepted technologies, the absence of an emerging or new disinfection technology from this manual should not be interpreted as precluding it from use. The above principles should be used to assess any new or novel disinfection technology. Where the technology is found to be effective, verifiable and cost effective it can be considered for use for the disinfection of drinking water. Characteristics of waterborne pathogens 1 2 Size Pathogen Resistance Relative Significance with respect to the ( m) to Chlorine Infectivity protection of human health Bacteria 0. Low Moderate Most cause gastro-intestinal illness but certain species may give rise to more Shigella spp Low High serious illnesses. Yersinia Low Low The majority are relatively sensitive to enterocolitica Low chlorination, and do not persist in the Campylobacter spp. Viruses Norovirus Moderate High leading to human infection tend to be specifically of human origin. They can Parvovirus Moderate High persist for long periods of time in the Adenovirus Moderate High environment and have a moderate resistance to chlorination. Helminths (Parasitic Worms) Visible Drancunculus Moderate High The reported incidence of infection in medinesis developed counties is very low, and does not present a hazard in relation to Schistosoma Moderate High treated drinking water supplies in Ireland 1 At conventional doses and contact times and with a pH between 7 and 8, Low means 99% inactivation at 20°C in generally, 1 minute, Moderate 1-30 minutes and High >30 minutes 2 From epidemiological evidence, High means infective doses between 1 - 100 organisms, Moderate 100- 10,000 and Low >10,000 Faeces of human origin are likely to present the greatest hazard since the range of pathogens will be the greatest and will include all pathogens types. In contrast, faeces of animal origin, predominantly arising from livestock although wildlife can be a significant source in certain situations, contain mainly pathogenic bacteria and protozoa with human pathogenic viruses being absent to a large extent. Bacterial microorganisms were chosen which were associated with faeces, which occurred in sufficiently higher numbers than the pathogens and which were relatively easy to isolate in the laboratory. The traditional role for these bacteria was as a measure of the extent of the pollution and an indication of the likelihood that pathogens associated with faeces may also be present in raw water.

The pattern with respect to both time and ized controlled trials including patients diet choice should be based on the patients’ amount (37) order levitra extra dosage 40 mg without prescription female erectile dysfunction treatment. By contrast buy 40mg levitra extra dosage otc erectile dysfunction treatment portland oregon, a simpler di- with type 2 diabetes have reported that health status and preferences. However, supplements carbohydrate intake for people with dia- dysfunction, and those for whom there do not seem to have the same effects. A betes are inconclusive, although monitor- are concerns over health literacy and nu- systematic review concluded that dietary ing carbohydrate intake and considering meracy (37–39,41,59,65). The modified supplements with v-3 fatty acids did not the blood glucose response to dietary car- plate method (which uses measuring improve glycemic control in individuals bohydrate are key for improving post- cups to assist with portion measure- with type 2 diabetes (61). The ment) may be an effective alternative controlled trials also do not support rec- literature concerning glycemic index and to carbohydrate counting for some pa- ommending v-3 supplements for primary glycemic load in individuals with diabetes tients in improving glycemia (70). A daily level of protein ingestion (typically saturated fat, dietary cholesterol, and systematic review (61) found that whole- 1–1. In general, trans fats should grain consumption was not associated total calories) will improve health in be avoided. Some may benefit blood pressure in certain cir- diabetes should be encouraged to replace research has found successful manage- cumstances (88). However, other studies refined carbohydrates and added sugars ment of type 2 diabetes with meal plans (89,90) have recommended caution for with whole grains, legumes, vegetables, including slightly higher levels of pro- universal sodium restriction to 1,500 mg and fruits. The consumption of sugar- tein (20–30%), which may contribute to in people with diabetes. Other benefits include slowing per week, spread over at least of benefit from herbal or nonherbal (i. Metformin is as- Exercise and Diabetes: A Position State- 75 min/week) of vigorous-intensity sociated with vitamin B12 deficiency, ment of the American Diabetes Asso- or interval training may be suffi- with a recent report from the Diabetes ciation” reviews the evidence for the cient for younger and more physi- Prevention Program Outcomes Study benefits of exercise in people with di- cally fit individuals. Routine supple- c All adults, and particularly those couraged to engage in at least 60 min mentation with antioxidants, such as with type 2 diabetes, should de- of physical activity each day. Chil- vitamins E and C and carotene, is not ad- crease the amount of time spent dren should engage in at least 60 min vised because of lack of evidence of effi- in daily sedentary behavior. B Pro- of moderate-to-vigorous aerobic activ- cacy and concern related to long-term longed sitting should be interrup- ity every day with muscle- and bone- safety. In addition, there is insufficient evi- ted every 30 min for blood glucose strengthening activities at least 3 days dence to support the routine use of herbals benefits, particularly in adults with per week (102). C type 1 diabetes benefit from being phys- and vitamin D (94), to improve glycemic c Flexibility training and balance ically active, and an active lifestyle control in people with diabetes (37,95). Alcohol times/week for older adults with Moderate alcohol consumption does diabetes. Yoga and tai chi may be Frequency and Type of Physical not have major detrimental effects on included based on individual pref- Activity long-termblood glucose control in people erences to increase flexibility, The U. C man Services’ physical activity guide- hol consumption include hypoglycemia lines for Americans (103) suggest that (particularly for those using insulin or in- adults over age 18 years engage in Physical activity is a general term that sulin secretagogue therapies), weight 150 min/week of moderate-intensity includes all movement that increases gain, and hyperglycemia (for those con- or 75 min/week of vigorous-intensity energy use and is an important part of suming excessive amounts) (37,95). In addition, Nonnutritive Sweeteners is a more specific form of physical activity the guidelines suggest that adults do For people who are accustomed to sugar- that is structured and designed to im- muscle-strengthening activities that in- sweetened products, nonnutritive sweet- prove physical fitness. Both physical activ- volve all major muscle groups 2 or more eners have the potential to reduce overall ity and exercise are important. The guidelines suggest that calorie and carbohydrate intake and may has beenshown to improve blood glucose adults over age 65 years and those with be preferred to sugar when consumed in control, reduce cardiovascular risk fac- disabilities follow the adult guidelines if moderation. Regulatory agencies set ac- tors, contribute to weight loss, and im- possible or, if not possible, be as physi- ceptable daily intake levels for each non- prove well-being. There are also considerable orous muscle-strengthening and risk and may also aid in glycemic control data for the health benefits (e. C muscle strength, improved insulin sensi- Physical Activity and Glycemic c Most adults with with type 1 C and tivity, etc. Higher levels Clinical trials have provided strong evi- 150 min or more of moderate-to- of exercise intensity are associated with dence for the A1C-lowering value of S38 Lifestyle Management Diabetes Care Volume 40, Supplement 1, January 2017 resistance training in older adults with provider should customize the exercise neuropathy who use proper footwear type 2 diabetes (106) and for an additive regimen to the individual’s needs. In addition, 150 min/week of mod- benefit of combined aerobic and resis- with complications may require a more erate exercise was reported to improve tance exercise in adults with type 2 diabe- thorough evaluation (98). All individuals with periph- with type 2 diabetes should be encour- Hypoglycemia eral neuropathy should wear proper aged to do at least two weekly sessions In individuals taking insulin and/or insu- footwear and examine their feet daily to of resistance exercise (exercise with free lin secretagogues, physical activity may detect lesions early. Anyone with a foot weights or weight machines), with each cause hypoglycemia if the medication injury or open sore should be restricted session consisting of at least one set dose or carbohydrate consumption is to non–weight-bearing activities. Individuals on these thera- Autonomic Neuropathy motions) of five or more different resis- pies may need to ingest some added Autonomic neuropathy can increase the tance exercises involving the large muscle carbohydrate if pre-exercise glucose risk of exercise-induced injury or ad- groups (106). Cardiovascu- dividual with type 1 diabetes has a duration of the activity (98,101).

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It may be no advantage at all if the granting State does not extend any favours to third States in the domain covered by the clause buy cheap levitra extra dosage 40 mg erectile dysfunction under 40. All that the most- favoured-nation clause promises is that the contracting party concerned will treat the other party as well as it treats any third State—which may be very badly discount levitra extra dosage 40mg online erectile dysfunction test yourself. It has been rightly said in this connection that, in the absence of any undertakings to third States, the clause remains but an empty shell. There is discrimination “de facto”, when the measure, while apparently being of general application, only affects the covered foreign investor. Mexico tribunal made a distinction between producers and resellers of cigarettes; the Champion Trading v. United States tribunal made a distinction between steel producers in general and those who could participate in a highway project. United States the tribunal established that “…it would be as perverse to ignore identical comparators if they were available and use comparators that were less like, as it would be perverse to refuse to find and apply less like comparators when no identical comparators exist”. Any other interpretation would negate the effect of the non-discriminatory provisions…” See Corn Products International Inc. Canada tribunal established that “Differences in treatment will presumptively violate Article 1102(2), unless they have a reasonable nexus to rational government policies that: (i) do not distinguish, on their face or de facto, between foreign-owned and domestic companies. However, an objective approach, where current international law concepts are considered, is generally used where multilaterals treaties dealing with human rights or maritime territory are in issue, being areas where international law has developed rapidly…” (Dixon and McCorquodale 2003). The treaty also specifies whether the treatment afforded to foreign investors and/or their investments is circumscribed to the post- establishment phase or whether it will apply to the pre-establishment phase as well. Illustrative examples of treaties can be found that identify the beneficiaries, covered phases of the investment cycle, conditions, exceptions and qualifications/clarifications. The post-establishment model is generally constructed through an “admission clause” in the basic treaty explicitly subjecting the entry of investments to the domestic legal framework. Each Contracting Party shall admit investments in accordance with its laws and regulations. Neither Contracting Party shall in its territory subject investments or returns of investors of the other Contracting Party to treatment less favourable than that which it accords, in like circumstances, to investments or returns of its own investors or to investments or returns of investors of any third State 2. Neither Contracting Party shall in any way impair by arbitrary or discriminatory measures the management, maintenance, use, enjoyment or disposal of investments in its territory of investors of the other Contracting Party. Article (3) National Treatment and Most-Favoured-Nation Treatment (1) Neither Contracting Parties shall in its territory subject investments owned or controlled by investors of the other Contracting Party to treatment less favourable than it accords to investments of own investors or to investments of investors of any third State. Energy Charter Treaty (1994) Article 10 Promotion, Protection and Treatment of Investment […] (2) Each Contracting Party shall endeavour to accord to Investors of other Contracting Parties, as regards the Making of Investments in its Area, the Treatment described in paragraph (3). That treaty shall be open for signature by the states and Regional Economic Integration Organizations which have signed or acceded to this Treaty. Negotiations towards the supplementary treaty shall commence not later than 1 January 1995, with a view to concluding it by 1 January 1998. This development can be explained by the fact that these treaties pursue liberalization objectives and see deeper investment commitments as interlinked with trade (particularly trade in services) disciplines. Pre-establishment covers the entry phase, which means that host States may not apply any discriminatory measure between foreigners as far as the entry conditions of the investor are concerned. In other words, under this model the host State accepts a certain limit on its sovereignty to regulate foreign investment. Given these far-reaching effects pre-establishment commitments are normally accompanied with specific country exceptions (through a “negative” or “positive” 1 list approach ) as opposed to the post-establishment model. There are variations as to liberalization commitments, notably when it comes to economic integration arrangements or regional agreements on investment. Each Party shall accord to investors of another Party treatment no less favorable than that it accords, in like circumstances, to investors of any other Party or of any non-Party with respect to the establishment, acquisition, expansion, management, conduct, operation, and sale or other disposition of investments in its territory. Each Party shall accord to covered investments treatment no less favorable than that it accords, in like circumstances, to investments in its territory of investors of any other Party or of any non-Party with respect to the establishment, acquisition, expansion, management, conduct, operation, and sale or other disposition of investments. The Parties agree to widen the scope of this Agreement to cover the right of establishment of one Party’s firms on the territory of the other and liberalisation of the provision of services by one Party’s firms to consumers of services in the other. The Association Council will make recommendations for achieving the objective described in paragraph 1. The Association Council will make a first assessment of the achievement of this objective no later than five years after this Agreement enters into force. There may be measures affecting the investment but not the investor, affecting the investor but not the investment or affecting both. By doing so the Contracting Parties substantially ease the commitment given that the investment shall be bound not only by the conditions of entry but also by any new measure issued in the form of a law or regulation by the host State (see box 12). Without prejudice to its laws and regulations, each Contracting party shall accord to investments and activities with such investments by the investors of the other Contraction Party treatment not less favorable than that accorded to the investments and associated activities by its own investors.

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Chlorine dioxide Can be more effective than chlorine at Weaker oxidant than ozone or chlorine cheap levitra extra dosage 40mg without a prescription erectile dysfunction caused by steroids. Potential for using chlorine for both Loss of residual in distribution systems primary disinfection and distribution discount 40 mg levitra extra dosage with mastercard erectile dysfunction treated by, with long residence times. Chloramination Needs effective control of process to avoid taste and odour due to either Stable residual with no significant by- dichloramine or trichloramine. Generally lower rate of non-chloraminated supplies in network taste and odour complaints than for can cause taste and odour issues. Chlorine dioxide Limited by consideration of inorganic by- product formation (chlorite and chlorate ). As set out above chemical disinfection methods are generally more effective against bacteria and viruses, with little or no effect in the case of chlorination for the inactivation of protozoan pathogens. However smaller chemical dosage is desirable to avoid or reduce by- product formation requiring a corresponding increase in contact time to achieve microbial inactivation. Turbidity in the water can encapsulate and protect pathogens from the action of chemical disinfectants. In general all chemical disinfectants are more effective for microbial inactivation, requiring reduced dosage, as temperature increases. The pH of the water, in the case of chlorination, has a significant effect on its effectiveness particularly requiring increases in the dosage rate above a value of 7. Ozone disinfection is not affected by pH in the common treated water range of 6-9. Rather than list all possible combinations of disinfectants, the following summarises areas that are likely to be of practical significance. Chlorine dioxide also shows a synergistic effect when combined with other disinfectants such as ozone, chlorine, and chloramines. Combination of disinfectants is known to lead to greater inactivation when the disinfectants are added in series rather than individually. Combination of disinfectants would need to take into account interactions between them. There are also benefits from two or more disinfectants in dealing with a range of different types of pathogen of different sensitivities to disinfectants e. However, it is unlikely that sufficiently large ozone residual would reach a final chlorination process, for such chlorate formation to be an issue. Chlorine also reacts with chlorine dioxide to produce chlorate, but it unlikely that these oxidants would be used in such a way as to allow this interaction to occur. Conversely there may be benefits to using chlorinated water to control biological nuisances. The concentrations of these organochlorine by-products are a function of the nature and concentration of oxidisable organic material in the water, the pH of the water, the water temperature, the free chlorine concentration, it’s contact time with the organic material but are not related to the type of chlorine source used. However, there are also inorganic by-products, particularly chlorate and bromate, which can result from the increased use of hypochlorite rather than chlorine gas, as the dosed chlorine chemical and its impact is greater with increasing storage time of the hypochlorite solution. The by-product issues of concern with the main disinfection processes are summarised in Table 3. Where chlorine is obtained from hypochlorite, chlorate and bromate formation can be an issue depending on bromide content of salt used in manufacture and subsequent conditions of storage of hypochlorite. Chlorine dioxide Dosage rates in the future are likely to be limited by consideration of inorganic by products (chlorate and chlorite) in accordance with current international practice. Surface water sources are more susceptible to organochlorine by-product formation than groundwaters because they receive organic matter in runoff from lake and river catchments. This organic matter comprises mostly humic substances from decaying vegetation, much of which can be in dissolved form as well as in colloid form. The concentration of this organic matter in surface water catchments can vary quickly after severe rainfall events or more slowly on a seasonal basis. The greater the portion which makes its way through the treatment process the greater the potential for the production of disinfection by-products. Following application of chlorine as part of the treatment process, organochlorine by-products can continue to form within downstream treated water storage and distribution systems depending on the length of retention times in storage tanks and pipelines and the strength of the disinfectant dose required to maintain chlorine residual in the peripheral areas of a distribution system. Journal Of Environmental Science and Health Part A Toxic/Hazardous Subst ances and Environmental Engineering 2009 Mar;44(4):336-9. In addition to its use as a primary disinfectant post treatment, the residual level which remains in the distribution systems ensures that the microbiological compliance can be quality assured to the consumer tap as well as safeguarding against recontamination in the distribution system. Chlorination is a relatively simple and cost effective process which does not require extensive technical expertise and which is capable of dealing with supply systems of varying size by altering dosing systems or storage for chemical contact accordingly. In Ireland, chlorination has historically been achieved using systems involving the storage and dosage of chlorine gas.

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