The F.A.Q. sites...........

Legionnaires disease

2007-01-26T23:39:00.000+01:00

Q. What is Legionnaires' disease?

A. Legionnaires' disease is a type of pneumonia that is caused by Legionella, a bacterium found primarily in warm water environments. Both the disease and the bacterium were discovered following an outbreak traced to a 1976 American Legion convention in Philadelphia. Pontiac fever, a flu-like illness, is also caused by Legionella organisms (legionellae), but is not as serious as Legionnaires' disease. Most people who get Pontiac fever recover within five days, without having to be hospitalized.

Q. What are the symptoms of Legionnaires' disease?

A. Legionnaires' disease develops within 2 to 10 days after exposure to legionellae. Initial symptoms may include loss of energy, headache, nausea, aching muscles, high fever (often exceeding 104°F), and chest pains. Later, many bodily systems as well as the mind may be affected. The disease eventually will cause death if the body’s high fever and antibodies cannot defeat it. Victims who survive may suffer permanent physical or mental impairment.

Q. Is Legionnaires disease common?

A. Legionnaires’ is not rare. It is perceived as rare only because most cases are never detected, and not all detected cases are reported to public health authorities. Because underdiagnosis and under-reporting make incidence of the disease difficult to estimate, figures have varied widely. The (U.S.) Centers for Disease Control and Prevention (CDC), Atlanta, has estimated that the disease infects 10,000 to 15,000 persons annually in the United States, but others have estimated as many as 100,000 annual U.S. cases.

Another reason that Legionnaires’ is falsely perceived as rare is that when cases are detected, the public rarely hears about them. Most cases—at least 65 to 80 percent in the United States and the United Kingdom —occur sporadically (one or two at a time). Thus, only a small percentage of cases occur as part of the multicase outbreaks that sometimes make the news. Cases of the disease are seldom publicized even when lawsuits are involved, because most Legionnaires’ lawsuits are settled quickly and under terms of confidentiality.

A case of Legionnaires’ disease will go undetected unless special laboratory tests are performed. Unfortunately, most U.S. hospitals still have not made these tests routinely available. It is reasonable to assume that undetected cases of Legionnaires’ are occurring because experience has shown that increased suspicion of the disease among physicians, when combined with increased patient testing, leads to more diagnoses. Some hospitals have recognized cases of Legionnaires’ disease only after increased testing of patients with pneumonia. Likewise, in hospitals where only one to three cases of Legionnaires’ were identified over several months, numerous additional cases were recognized after surveillance was intensified.

Studies of community-acquired pneumonia (cases acquired outside hospitals) have also indicated that increased surveillance leads to more diagnoses. A large-scale study in Ohio (U.S.A.) suggested that only 3 percent of sporadic cases of Legionnaires’ disease were correctly diagnosed. By comparison, in studies in which diagnostic tests have been consistently used, Legionella has been recognized among the top three or four microbial causes of community-acquired pneumonia.

Because the symptoms of Legionnaires’ are similar to those of other types of pneumonia, undetected cases of Legionnaires’ disease end up being classified merely as pneumonia with no apparent cause. Based on CDC estimates, this means that 8 to 39 pneumonia deaths occur each week in the United States without anyone knowing that the cause was Legionella. What’s worse is that many of these deaths could be prevented because, unlike most pneumonias, the source (e.g., a hot-water system) of Legionnaires’ cases can be identified. But if Legionella is not recognized as the cause, no investigation ensues to pinpoint and disinfect the source, so the same source remains a threat.

Q. How is Legionnaires' disease treated?

A. Erythromycin and Azithromycin, antibiotics, have been effective, especially when cases are detected early.

Q. How does a person get Legionnaires' disease?

A. Legionnaires' disease is contracted by inhaling airborne water droplets containing legionellae. Some investigators believe that the disease may be acquired also by drinking legionellae-contaminated water, particularly if legionellae aspirated from the water are inhaled before the water enters the stomach. Cases have also been blamed on contact between contaminated water and incisions or skin wounds.The disease is not contagious.

Q. Who is at risk of contracting Legionnaires disease?

A. The risk of infection is based on two key factors: the number of legionellae reaching the body and the resistance of the individual. Young and healthy people can get Legionnaires’ disease, but persons who are immunocompromised either because of illness (e.g., cancer) or medical treatment (e.g., chemotherapy) are at a much higher risk because they can be infected by relatively low legionellae counts. HIV-infected patients, for example, have a 40-fold increased risk; organ transplant recipients have a 200-fold increased risk. Smokers, persons over 65 years of age, and heavy drinkers have a moderately higher risk.

Children have contracted Legionnaires' disease. Most cases have occurred in immunosuppressed children, but a number of immunocompetent children, particularly newborns, have acquired the disease, most often after surgeries, or through the use of legionellae-contaminated ventilators.

Q. What is the death rate?

A. Underlying disease and advanced age not only increase the risk of contracting Legionnaires’ disease but also the risk of dying from it, so it is not surprising that a CDC study of reported cases indicated a death rate of 40 percent for cases acquired during a hospital stay (nosocomial cases), but a death rate of 20 percent for community-acquired cases. Some outbreaks have claimed more than 50 percent.

Q. Can the risk of Legionnaires' Disease be determined by geographical location?

A. No. Legionnaires’ disease is not specific only to certain areas. Although some areas have reported more cases of LD than other areas, the geographic location is relatively insignificant. What’s more, the number of cases reported from a given area could indicate the level of awareness among physicians and the availability of laboratory testing, as opposed to the level of legionellae in the water supply. Legionella contamination is usually tied to the condition of a building’s mechanical system, which is independent of geographical location.

Q. What is the size of Legionella organisms?

A. The average Legionella cell is 0.5-1.0 micrometer wide and 1.0-3.0 micrometers long (Barbaree, J. M. "Controlling Legionella in Cooling Towers," ASHRAE Journal, June 1991; 38-42).

Q. What are the long term side effects of Legionnaires disease? I heard asthma is one side effect.

A. As with any acute illness, patients who recover from Legionnaires' disease can suffer long term side effects. The most common are fatigue and lack of energy for several months. However, asthma of new onset is uncommon, although I know of a few cases who have persistent chest x-ray abnormalities with sustained wheezing. It is unclear as to whether this can be blamed solely on Legionnaires' disease; asthma may be due to a number of stresses besides Legionnaires' disease. Answer provided by Victor L. Yu, MD, Professor of Medicine, Unviersity of Pittsburgh; Chief, Infectious Disease Section, VA Medical Center, Pittsburgh, PA, USA.

Q. I have had Legionnaire's disease and been treated with large doses of erythromycin. The disease nearly killed me. My temperature was 107 degrees F; I was at death's door. Luckily, I had a physician who stayed by my side for days and suspected Legionnaire's. After having a near-death experience, I want to make sure that this never happens to me or any of my loved ones again. Is there any chance that the bacteria are still in my system, remaining a threat? Deborah Newman

A. I am sorry that you had such a punishing experience with Legionnaires' disease (LD) , but I am also thankful that you survived since the mortality can be high. The answer to your question has only been clearly elucidated in the last decade. In 1978, when I saw my first case, we wondered if this could occur and our blood antibody tests suggested that it might have occurred in two patients. But, more complete studies with newer and more powerful lab tests have shown that once you are cured with antibiotics, the bacteria are cleared. So, you do not have to worry about this. We have data on the largest collection of patients with LD in the world and have followed them for many years. Somewhat to our surprise, virtually none of them have become reinfected. Apparently, they developed immunity with their first infection. It appears that you have some residual protection if you contract Legionnaire's disease; however, the most effective method of prevention is stopping cigarette smoking. Smokers are much more likely to contract LD (as they are to contract other respiratory infections including the flu). Fever exceeding 104.5 is a hallmark of LD, so you should thank your MD for making that fine diagnosis. Answer provided by Victor L. Yu, MD, Professor of Medicine, Unviersity of Pittsburgh; Chief, Infectious Disease Section, VA Medical Center, Pittsburgh, PA, USA.

Q. I have a friend who has been diagnosed with Legionnaires disease and is in the critical care department of a local hospital. Is this a disease that is mandated to be reported to the (U.S.) CDC? Will there be follow up on the source of the bacteria?

A. In the United States, Legionaires' disease is a reportable disease by law to the local public health department and the CDC. Most health departments will not do a follow-up unless many patients contract the illness. Answer provided by Victor L. Yu, MD, Professor of Medicine, Unviersity of Pittsburgh; Chief, Infectious Disease Section, VA Medical Center, Pittsburgh, PA, USA.

Q. What can I do to make my home less conducive to Legionella contamination?

A. The plumbing system (via showers and faucets), whirlpool spas and bathtubs, and humidifiers present a potential risk of legionellae exposure in homes. A number of measures can be taken to minimize legionellae growth. The long list of risk reduction options for homes cannot be covered in this brief FAQ. For more information, see our publications for homes.

Q. Are certain types of buildings more prone than others to have problems with legionellae?

A. Cases of Legionnaires' disease have been linked to many types of equipment that contain water, but plumbing systems and air conditioning systems are most often blamed. Although it is possible to contract the illness from legionellae growing in home plumbing systems, most cases have been traced to large buildings. This may be because larger piping networks are generally more conducive to legionellae growth. Also, the air conditioning systems for large buildings often include cooling towers, which contain a pool of warm water in which legionellae can flourish.

Q. What precautions can be taken to prevent Legionnaires' disease?

A. Legionnaires' is considered an environmental disease because its causative agent (legionellae) is transmitted from an environmental source (water) to a person (in contrast with communicable diseases, such as AIDS, which are transmitted from person to person). Therefore, keeping legionellae out of water is the key to preventing the disease. For example, plumbing systems can be maintained to minimize the growth of legionellae. And if preventive measures alone do not control the bacteria, disinfection procedures can be implemented.

Q. How can I reduce my risk of getting Legionnaires' disease?

A. You can reduce your risk of Legionnaires’ disease by (a) lowering your susceptibility to infection and (b) avoiding exposure to Legionella bacteria. The most important factor in lowering your susceptibility to infection is to stop smoking. Among persons who are not immunocompromised, smoking is the number one factor in acquiring Legionnaires disease. A study of 146 adults with Legionnaires’ disease indicated that smoking sharply increased the risk of contracting the disease. As for avoiding exposure to legionellae, you have several options. Some measures cost nothing and should be implemented out of good sense. Expensive measures could be a waste of money for healthy nonsmoking adults, who are at low risk of contracting Legionaires disease. High-risk individuals, however, should consider taking every reasonable precaution. For more information on avoiding exposure to legionellae in public places, see our electronic publication entitled How to reduce your risk of Legionnaires’ disease in public places. For information on reducing your exposure to legionellae at home, see our publications for homes.

Q. What precautions should be taken in working on cooling towers?

A. Experts recommend wearing a high-efficiency particulate air (HEPA) protective mask while cleaning cooling towers or collecting samples from them, unless the tower fans are shut off, especially if legionellae contamination is suspected or hyperchlorination is in process. Full masks allow less leakage and thus filter more than half masks. A good fit is critical with any mask. Be aware, however, that HEPA filters will not block all bacteria. Gloves, goggles, and other body coverings have also been suggested for cooling tower work. Return to top

Fever (normal fever)

2007-01-24T19:29:00.000+01:00

What is fever ?

Fever is defined in medical terms as a body temperature of more than 37 degrees Celsius. We often are more familiar with using the Fahrenheit Scale – in which any temperature over 98.6 is defined as fever.

Medical word for fever :
The technical term for fever is Pyrexia.

Why does a person have fever ?

Fever is the body’s natural defense mechanism and is better understood as an external appearance of the internal fight going on between the infectious agent
( any germ , virus or bacteria that are causing an infection ) and the body’s immune system. From this brief background it is easy to follow that fever is usually the first external manifestation of the internal disturbance. It is fever that brings the person to the doctor and we thus call it a parent’s friend than a foe ! Were is not for fever – perhaps the internal disturbance would go on unchecked till point of no control before one sought medical advice.

When is fever significant ?

Though any rise in body temperature is counted as fever and should be a cause for concern – there are some situations when the “ fever “ may be a “ normal phenomenon” : for example in extremely hot seasons newborns may develop a short lasting “ fever “ that may not be of concern as long as the newborn is doing well otherwise. This is known as “ Environmental Pyrexia” and needs only to reduce the room temperature and to reduce the child’s clothing and then monitor the temperature again after some ½ - 1 hour – if raised temperature persists then you certainly need to consult your Pediatrician soon as possible.

Is infection the only cause of fever ?

Though infections are the overwhelmingly leading cause of fever – some other diseases or other problems may also cause fever. These may lie beyond the common understanding of lay people and are best addressed by your Pediatrician than your jumping to conclusions.

High Thyroid state ( Hyperthyroidism) , other hormonal disturbances such as may occur at menopause , poor sweating capacity ( a specific disease ) and other esoteric and remote causes also exist .

Interestingly , drugs ( any drug for that matter ) may cause fever and is known medically as Drug Induced Pyrexia. Elimination of all drugs and then watching the fever pattern is a step often taken by Doctors in such situations.

Anyhow – for all practical purposes , a lay person may well presume that all fevers ARE caused by infections and seek advice soon as possible.

How should I measure temperature :

Temperature is best measured by the conventional method of taking the underarm temperature or the mouth temperature.The more scientific method ( and of special use in newborns ) is measurement of rectal temperature.This more accurate method has its serious handicap of being dangerous in untrained hands. Some newly devised instruments measure the temperature inside the ear ( known as Aural Temperature ) - it is a very good and child friendly method though the instrument is not easily available in India.

The commonly available Thermometers are known as Clinical Thermometers ( as against those used for measuring room temperatures and those used in chemical and physical laboratories ). Two commonly available instruments are the cheaper Mercury Thermometer and the costlier Digital one. The mercury one is fairly reliable though it has the hazard of mercury spillage in the mouth if the child bites the tip – hence we usually recommend underarm recording.

Shake your mercury thermometer properly so that the silvery looking fine line of mercury falls well below the arrow mark ( usually set at 98.6 degrees F , or 37 degrees Celsius ) and then keep the mercury tip in the underarm for the time specified on the instrument ( usually 1 minute ) . Take the reading after that time and ADD 1 degree for correction – this added value gives you the correct body temperature reading. If used in the mouth – keep the mercury tip under the tongue for the specified time and DO NOT ADD any further value – mouth reading is to be recorded as such.

Any instrument is prone to inaccuracies and clinical experience abounds with stories of hectic investigation and unnecessary treatment for instrumental error giving “Fever”. It helps to try out a newly purchased instrument on yourself and some other members of the family who you feel do not have fever.

The Digital ones are very easy to use and usually give an audible alarm when the reading is complete. Their higher cost is fairly justified by the convenience and risk free usage they offer . The precaution of taking any electronic instrument with a pinch of salt has always to be kept in mind – do calibrate it the way we recommend for the ordinary mercury device.

What is the first aid I should give for fever ?

Paracetamol ( known in the Western world as Acetaminophen ) is by far the best medicine for fever and usually will take care of any type or degree of fever.

The commonly available brands in the Indian market are : Crocin , Calpol , Metacin ( available as 500 mg tablets , syrups containing 125 mg per 5 ml and drops containing 125 mg per ml where 1 ml has some 16 drops to it ).

As a thumb rule a child needs some 10 mg per kilogram of bodyweight as a dose and one can give it as frequently as every 4 hourly if needed. The syrup works out to a ready calculation of one 5 ml measure per 10 kilogram body weight and the drops work out to double the number of drops as the body weight in kilograms.

The other commonly available and used preparations are Ibuprofen ( Brands : Brufen , Ibugesic ) ; Ibuprofen and Paracetamol combinations ( common brands : Combiflam , Ibugesic Plus ) ; Nimesulide ( common brands : Nimulid , Nise ) and a host of other formulations and combinations.

What else can I do for reducing fever apart from medicines ?

Sponging of the body is a commonly known method of reducing temperature but there are several myths and fallacies relating to the correct technique. For your understanding – sponging with water causes reduction in body temperature by heat loss through evaporation of water on a hot body surface.

1 The water should NOT be cold ( as is commonly understood by Cold Water Sponging ) – it should instead be lukewarm / tepid. Cold water causes shrinkage ( constriction ) of the blood capillaries under the skin and causes poor blood flow to the skin – resulting in poor heat flow to the surface of the body and poor effect of sponging.

2 The whole body needs to be sponged and NOT just the forehead and exposed limbs as is commonly practised. The larger the surface area sponged the better the results. Thus you need to expose the whole body by making the child naked and wipe the whole body with a tepid / lukewarm cloth and then leave the body exposed naked for a while and the clothe the child. Clothing soon after sponging causes paradoxical rise in temperature by trapping body heat in the cloth – body surface interface.

3 Sponge as frequently as needed – you may need some 3-4 spongings for good effect.

How often do I need to measure fever ?

It depends on the need of the parent and the need of the Doctor.
As a parent you may need to measure whenever you feel the child has fever.

Your Doctor may , at the same time ask you to measure fever on a fixed schedule for a certain number of days. What he is looking for is a specific pattern ( i.e. is the fever more in the evenings , does the fever have a once a day spike , does the fever continue throughout the day and so on ) – he shall draw his conclusions based on this pattern on fever.

As a general rule – and specifically so for prolonged fevers – a thrice daily schedule is optimum – morning , late afternoon and night. You may do well to maintain a chart such as below and also keep a column for any observations you make with the fever pattern – such as chills.

Bird Flu

2007-01-23T21:48:00.000+01:00

What is avian influenza?

Avian influenza, or “bird flu”, is a contagious disease of animals caused by viruses that normally infect only birds and, less commonly, pigs. Avian influenza viruses are highly species-specific, but have, on rare occasions, crossed the species barrier to infect humans.

In domestic poultry, infection with avian influenza viruses causes two main forms of disease, distinguished by low and high extremes of virulence. The so-called “low pathogenic” form commonly causes only mild symptoms (ruffled feathers, a drop in egg production) and may easily go undetected. The highly pathogenic form is far more dramatic. It spreads very rapidly through poultry flocks, causes disease affecting multiple internal organs, and has a mortality that can approach 100%, often within 48 hours.

Which viruses cause highly pathogenic disease?

Influenza A viruses1 have 16 H subtypes and 9 N subtypes2. Only viruses of the H5 and H7 subtypes are known to cause the highly pathogenic form of the disease. However, not all viruses of the H5 and H7 subtypes are highly pathogenic and not all will cause severe disease in poultry.

On present understanding, H5 and H7 viruses are introduced to poultry flocks in their low pathogenic form. When allowed to circulate in poultry populations, the viruses can mutate, usually within a few months, into the highly pathogenic form. This is why the presence of an H5 or H7 virus in poultry is always cause for concern, even when the initial signs of infection are mild.

Do migratory birds spread highly pathogenic avian influenza viruses?

The role of migratory birds in the spread of highly pathogenic avian influenza is not fully understood. Wild waterfowl are considered the natural reservoir of all influenza A viruses. They have probably carried influenza viruses, with no apparent harm, for centuries. They are known to carry viruses of the H5 and H7 subtypes, but usually in the low pathogenic form. Considerable circumstantial evidence suggests that migratory birds can introduce low pathogenic H5 and H7 viruses to poultry flocks, which then mutate to the highly pathogenic form.

In the past, highly pathogenic viruses have been isolated from migratory birds on very rare occasions involving a few birds, usually found dead within the flight range of a poultry outbreak. This finding long suggested that wild waterfowl are not agents for the onward transmission of these viruses.

Recent events make it likely that some migratory birds are now directly spreading the H5N1 virus in its highly pathogenic form. Further spread to new areas is expected.

What is special about the current outbreaks in poultry?

The current outbreaks of highly pathogenic avian influenza, which began in South-East Asia in mid-2003, are the largest and most severe on record. Never before in the history of this disease have so many countries been simultaneously affected, resulting in the loss of so many birds.

The causative agent, the H5N1 virus, has proved to be especially tenacious. Despite the death or destruction of an estimated 150 million birds, the virus is now considered endemic in many parts of Indonesia and Viet Nam and in some parts of Cambodia, China, Thailand, and possibly also the Lao People’s Democratic Republic. Control of the disease in poultry is expected to take several years.

The H5N1 virus is also of particular concern for human health, as explained below.

Which countries have been affected by outbreaks in poultry?

From mid-December 2003 through early February 2004, poultry outbreaks caused by the H5N1 virus were reported in eight Asian nations (listed in order of reporting): the Republic of Korea, Viet Nam, Japan, Thailand, Cambodia, Lao People’s Democratic Republic, Indonesia, and China. Most of these countries had never before experienced an outbreak of highly pathogenic avian influenza in their histories.

In early August 2004, Malaysia reported its first outbreak of H5N1 in poultry, becoming the ninth Asian nation affected. Russia reported its first H5N1 outbreak in poultry in late July 2005, followed by reports of disease in adjacent parts of Kazakhstan in early August. Deaths of wild birds from highly pathogenic H5N1 were reported in both countries. Almost simultaneously, Mongolia reported the detection of H5N1 in dead migratory birds. In October 2005, H5N1 was confirmed in poultry in Turkey and Romania. Outbreaks in wild and domestic birds are under investigation elsewhere.

Japan, the Republic of Korea, and Malaysia have announced control of their poultry outbreaks and are now considered free of the disease. In the other affected areas, outbreaks are continuing with varying degrees of severity.

What are the implications for human health?

The widespread persistence of H5N1 in poultry populations poses two main risks for human health.

The first is the risk of direct infection when the virus passes from poultry to humans, resulting in very severe disease. Of the few avian influenza viruses that have crossed the species barrier to infect humans, H5N1 has caused the largest number of cases of severe disease and death in humans. Unlike normal seasonal influenza, where infection causes only mild respiratory symptoms in most people, the disease caused by H5N1 follows an unusually aggressive clinical course, with rapid deterioration and high fatality. Primary viral pneumonia and multi-organ failure are common. In the present outbreak, more than half of those infected with the virus have died. Most cases have occurred in previously healthy children and young adults.

A second risk, of even greater concern, is that the virus – if given enough opportunities – will change into a form that is highly infectious for humans and spreads easily from person to person. Such a change could mark the start of a global outbreak (a pandemic).

Where have human cases occurred?

In the current outbreak, laboratory-confirmed human cases have been reported in four countries: Cambodia, Indonesia, Thailand, and Viet Nam.

Hong Kong has experienced two outbreaks in the past. In 1997, in the first recorded instance of human infection with H5N1, the virus infected 18 people and killed 6 of them. In early 2003, the virus caused two infections, with one death, in a Hong Kong family with a recent travel history to southern China.

How do people become infected?

Direct contact with infected poultry, or surfaces and objects contaminated by their faeces, is presently considered the main route of human infection. To date, most human cases have occurred in rural or periurban areas where many households keep small poultry flocks, which often roam freely, sometimes entering homes or sharing outdoor areas where children play. As infected birds shed large quantities of virus in their faeces, opportunities for exposure to infected droppings or to environments contaminated by the virus are abundant under such conditions. Moreover, because many households in Asia depend on poultry for income and food, many families sell or slaughter and consume birds when signs of illness appear in a flock, and this practice has proved difficult to change. Exposure is considered most likely during slaughter, defeathering, butchering, and preparation of poultry for cooking.

Is it safe to eat poultry and poultry products?

Yes, though certain precautions should be followed in countries currently experiencing outbreaks. In areas free of the disease, poultry and poultry products can be prepared and consumed as usual (following good hygienic practices and proper cooking), with no fear of acquiring infection with the H5N1 virus.

In areas experiencing outbreaks, poultry and poultry products can also be safely consumed provided these items are properly cooked and properly handled during food preparation. The H5N1 virus is sensitive to heat. Normal temperatures used for cooking (70oC in all parts of the food) will kill the virus. Consumers need to be sure that all parts of the poultry are fully cooked (no “pink” parts) and that eggs, too, are properly cooked (no “runny” yolks).

Consumers should also be aware of the risk of cross-contamination. Juices from raw poultry and poultry products should never be allowed, during food preparation, to touch or mix with items eaten raw. When handling raw poultry or raw poultry products, persons involved in food preparation should wash their hands thoroughly and clean and disinfect surfaces in contact with the poultry products Soap and hot water are sufficient for this purpose.

In areas experiencing outbreaks in poultry, raw eggs should not be used in foods that will not be further heat-treated as, for example by cooking or baking.

Avian influenza is not transmitted through cooked food. To date, no evidence indicates that anyone has become infected following the consumption of properly cooked poultry or poultry products, even when these foods were contaminated with the H5N1 virus.

Does the virus spread easily from birds to humans?

No. Though more than 100 human cases have occurred in the current outbreak, this is a small number compared with the huge number of birds affected and the numerous associated opportunities for human exposure, especially in areas where backyard flocks are common. It is not presently understood why some people, and not others, become infected following similar exposures.

What about the pandemic risk?

A pandemic can start when three conditions have been met: a new influenza virus subtype emerges; it infects humans, causing serious illness; and it spreads easily and sustainably among humans. The H5N1 virus amply meets the first two conditions: it is a new virus for humans (H5N1 viruses have never circulated widely among people), and it has infected more than 100 humans, killing over half of them. No one will have immunity should an H5N1-like pandemic virus emerge.

All prerequisites for the start of a pandemic have therefore been met save one: the establishment of efficient and sustained human-to-human transmission of the virus. The risk that the H5N1 virus will acquire this ability will persist as long as opportunities for human infections occur. These opportunities, in turn, will persist as long as the virus continues to circulate in birds, and this situation could endure for some years to come.

What changes are needed for H5N1 to become a pandemic virus?

The virus can improve its transmissibility among humans via two principal mechanisms. The first is a “reassortment” event, in which genetic material is exchanged between human and avian viruses during co-infection of a human or pig. Reassortment could result in a fully transmissible pandemic virus, announced by a sudden surge of cases with explosive spread.

The second mechanism is a more gradual process of adaptive mutation, whereby the capability of the virus to bind to human cells increases during subsequent infections of humans. Adaptive mutation, expressed initially as small clusters of human cases with some evidence of human-to-human transmission, would probably give the world some time to take defensive action.

What is the significance of limited human-to-human transmission?

Though rare, instances of limited human-to-human transmission of H5N1 and other avian influenza viruses have occurred in association with outbreaks in poultry and should not be a cause for alarm. In no instance has the virus spread beyond a first generation of close contacts or caused illness in the general community. Data from these incidents suggest that transmission requires very close contact with an ill person. Such incidents must be thoroughly investigated but – provided the investigation indicates that transmission from person to person is very limited – such incidents will not change the WHO overall assessment of the pandemic risk. There have been a number of instances of avian influenza infection occurring among close family members. It is often impossible to determine if human-to-human transmission has occurred since the family members are exposed to the same animal and environmental sources as well as to one another.

How serious is the current pandemic risk?

The risk of pandemic influenza is serious. With the H5N1 virus now firmly entrenched in large parts of Asia, the risk that more human cases will occur will persist. Each additional human case gives the virus an opportunity to improve its transmissibility in humans, and thus develop into a pandemic strain. The recent spread of the virus to poultry and wild birds in new areas further broadens opportunities for human cases to occur. While neither the timing nor the severity of the next pandemic can be predicted, the probability that a pandemic will occur has increased.

Are there any other causes for concern?

Yes. Several.

• Domestic ducks can now excrete large quantities of highly pathogenic virus without showing signs of illness, and are now acting as a “silent” reservoir of the virus, perpetuating transmission to other birds. This adds yet another layer of complexity to control efforts and removes the warning signal for humans to avoid risky behaviours.

• When compared with H5N1 viruses from 1997 and early 2004, H5N1 viruses now circulating are more lethal to experimentally infected mice and to ferrets (a mammalian model) and survive longer in the environment.

• H5N1 appears to have expanded its host range, infecting and killing mammalian species previously considered resistant to infection with avian influenza viruses.

• The behaviour of the virus in its natural reservoir, wild waterfowl, may be changing. The spring 2005 die-off of upwards of 6,000 migratory birds at a nature reserve in central China, caused by highly pathogenic H5N1, was highly unusual and probably unprecedented. In the past, only two large die-offs in migratory birds, caused by highly pathogenic viruses, are known to have occurred: in South Africa in 1961 (H5N3) and in Hong Kong in the winter of 2002–2003 (H5N1).

Why are pandemics such dreaded events?

Influenza pandemics are remarkable events that can rapidly infect virtually all countries. Once international spread begins, pandemics are considered unstoppable, caused as they are by a virus that spreads very rapidly by coughing or sneezing. The fact that infected people can shed virus before symptoms appear adds to the risk of international spread via asymptomatic air travellers.

The severity of disease and the number of deaths caused by a pandemic virus vary greatly, and cannot be known prior to the emergence of the virus. During past pandemics, attack rates reached 25-35% of the total population. Under the best circumstances, assuming that the new virus causes mild disease, the world could still experience an estimated 2 million to 7.4 million deaths (projected from data obtained during the 1957 pandemic). Projections for a more virulent virus are much higher. The 1918 pandemic, which was exceptional, killed at least 40 million people. In the USA, the mortality rate during that pandemic was around 2.5%.

Pandemics can cause large surges in the numbers of people requiring or seeking medical or hospital treatment, temporarily overwhelming health services. High rates of worker absenteeism can also interrupt other essential services, such as law enforcement, transportation, and communications. Because populations will be fully susceptible to an H5N1-like virus, rates of illness could peak fairly rapidly within a given community. This means that local social and economic disruptions may be temporary. They may, however, be amplified in today’s closely interrelated and interdependent systems of trade and commerce. Based on past experience, a second wave of global spread should be anticipated within a year.

As all countries are likely to experience emergency conditions during a pandemic, opportunities for inter-country assistance, as seen during natural disasters or localized disease outbreaks, may be curtailed once international spread has begun and governments focus on protecting domestic populations.

What are the most important warning signals that a pandemic is about to start?

The most important warning signal comes when clusters of patients with clinical symptoms of influenza, closely related in time and place, are detected, as this suggests human-to-human transmission is taking place. For similar reasons, the detection of cases in health workers caring for H5N1 patients would suggest human-to-human transmission. Detection of such events should be followed by immediate field investigation of every possible case to confirm the diagnosis, identify the source, and determine whether human-to-human transmission is occurring.

Studies of viruses, conducted by specialized WHO reference laboratories, can corroborate field investigations by spotting genetic and other changes in the virus indicative of an improved ability to infect humans. This is why WHO repeatedly asks affected countries to share viruses with the international research community.

What is the status of vaccine development and production?

Vaccines effective against a pandemic virus are not yet available. Vaccines are produced each year for seasonal influenza but will not protect against pandemic influenza. Although a vaccine against the H5N1 virus is under development in several countries, no vaccine is ready for commercial production and no vaccines are expected to be widely available until several months after the start of a pandemic.

Some clinical trials are now under way to test whether experimental vaccines will be fully protective and to determine whether different formulations can economize on the amount of antigen required, thus boosting production capacity. Because the vaccine needs to closely match the pandemic virus, large-scale commercial production will not start until the new virus has emerged and a pandemic has been declared. Current global production capacity falls far short of the demand expected during a pandemic.

What drugs are available for treatment?

Two drugs (in the neuraminidase inhibitors class), oseltamivir (commercially known as Tamiflu) and zanamivir (commercially known as Relenza) can reduce the severity and duration of illness caused by seasonal influenza. The efficacy of the neuraminidase inhibitors depends, among others, on their early administration ( within 48 hours after symptom onset). For cases of human infection with H5N1, the drugs may improve prospects of survival, if administered early, but clinical data are limited. The H5N1 virus is expected to be susceptible to the neuraminidase inhibitors. Antiviral resistance to neuraminidase inhibitors has been clinically negligible so far but is likely to be detected during widespread use during a pandemic.

An older class of antiviral drugs, the M2 inhibitors amantadine and rimantadine, could potentially be used against pandemic influenza, but resistance to these drugs can develop rapidly and this could significantly limit their effectiveness against pandemic influenza. Some currently circulating H5N1 strains are fully resistant to these the M2 inhibitors. However, should a new virus emerge through reassortment, the M2 inhibitors might be effective.

For the neuraminidase inhibitors, the main constraints – which are substantial – involve limited production capacity and a price that is prohibitively high for many countries. At present manufacturing capacity, which has recently quadrupled, it will take a decade to produce enough oseltamivir to treat 20% of the world’s population. The manufacturing process for oseltamivir is complex and time-consuming, and is not easily transferred to other facilities.

So far, most fatal pneumonia seen in cases of H5N1 infection has resulted from the effects of the virus, and cannot be treated with antibiotics. Nonetheless, since influenza is often complicated by secondary bacterial infection of the lungs, antibiotics could be life-saving in the case of late-onset pneumonia. WHO regards it as prudent for countries to ensure adequate supplies of antibiotics in advance.

Can a pandemic be prevented?

No one knows with certainty. The best way to prevent a pandemic would be to eliminate the virus from birds, but it has become increasingly doubtful if this can be achieved within the near future.

Following a donation by industry, WHO will have a stockpile of antiviral medications, sufficient for 3 million treatment courses, by early 2006. Recent studies, based on mathematical modelling, suggest that these drugs could be used prophylactically near the start of a pandemic to reduce the risk that a fully transmissible virus will emerge or at least to delay its international spread, thus gaining time to augment vaccine supplies.

The success of this strategy, which has never been tested, depends on several assumptions about the early behaviour of a pandemic virus, which cannot be known in advance. Success also depends on excellent surveillance and logistics capacity in the initially affected areas, combined with an ability to enforce movement restrictions in and out of the affected area. To increase the likelihood that early intervention using the WHO rapid-intervention stockpile of antiviral drugs will be successful, surveillance in affected countries needs to improve, particularly concerning the capacity to detect clusters of cases closely related in time and place.

What strategic actions are recommended by WHO?

In August 2005, WHO sent all countries a document outlining recommended strategic actions for responding to the avian influenza pandemic threat. Recommended actions aim to strengthen national preparedness, reduce opportunities for a pandemic virus to emerge, improve the early warning system, delay initial international spread, and accelerate vaccine development.

Is the world adequately prepared?

No. Despite an advance warning that has lasted almost two years, the world is ill-prepared to defend itself during a pandemic. WHO has urged all countries to develop preparedness plans, but only around 40 have done so. WHO has further urged countries with adequate resources to stockpile antiviral drugs nationally for use at the start of a pandemic. Around 30 countries are purchasing large quantities of these drugs, but the manufacturer has no capacity to fill these orders immediately. On present trends, most developing countries will have no access to vaccines and antiviral drugs throughout the duration of a pandemic.

taken from:-
http://www.who.int/csr/disease/avian_influenza/avian_faqs/en/index.html

Parkinson disease

2007-01-21T21:03:00.000+01:00

What is Parkinson's?

Parkinson's is a progressive disorder of the central nervous system that may lead to tremors, rigidity, slowness of movements, gait disorder and a loss of balance. It's important to know that every case is different and that not all people with Parkinson's will experience all symptoms.

There is an area of the brain called the substantia nigra that contains specialized cells that produce dopamine, a chemical that allows the smooth transition of nerve impulses among nerve cells. These impulses are necessary to the transmission of voluntary-movement messages to the muscles. When these specialized cells die, there is a dopamine deficiency. This results in interference in the transmission of the messages and can make voluntary movement difficult. Such a condition is known as Parkinson's.

What causes Parkinson's and who gets the disease?

Research to date has not been able to identify the exact cause of this condition. There is evidence to suggest that some people may have a genetic predisposition to Parkinson's, but there is no clear evidence to suggest that it is hereditary. Other risk factors that have been identified are head injury, direct occupational pesticide exposure and the age-related loss of brain cells that transmit nerve impulses.

Despite popular belief, Parkinson's is not found only in the elderly. As many as one out of five Parkinson's cases are found in people under 50 years of age.

Parkinson's is one of the most common neurological disorders and affects one out of every 100 adults in Canada. Parkinson's affects men and women equally and the disease crosses all ethnic lines.

Is there a cure?

Although there is no cure, modern treatments and therapies can allow people with Parkinson's to lead active lives.

What are the treatments?

Medications are most commonly used to treat Parkinson's although some people may require brain surgery. Medications are prescribed to help control symptoms and aid in the flow of dopamine within the brain.

The most common medication is levodopa, a chemical that the body converts into dopamine. Other drugs may be used to decrease the dopamine breakdown in the body, enhance the release of dopamine or stimulate the dopamine receptors.

Surgical treatments may include:

Pallidotomy/Thalamotomy - Thalamotomy procedures involves making tiny scars in the thalamus region of the brain by inserting small stereotactic needles. This procedure is usually used to treat severe, one-sided tremors. Pallidotomy involves a similar technique but in the globus pallidus section of the brain. It is usually reserved for people with bradykinesia (slowness in movement). It is not clear if either procedure delays the progress of the disease.

Deep Brain Stimulation - This is a new technique where a small electrode, placed in the brain, emits a current that affects the faulty signals. The electrode is connected to a pacemaker-like device that is placed in the patient's chest near the collarbone. Patients use a hand-held device to turn it on and off.

Tissue Transplantation - This type of operation is still experimental. Because Parkinson's relates primarily to the degeneration of the cells that make dopamine, tissue transplantation aims to replace these cells with healthy ones.

In addition to these treatments, an exercise program or speech and occupational therapy may be prescribed.

Is Parkinson's fatal?

Research shows that Parkinson's is not fatal. A recent study, however, indicates that "mortality is two to five times as high among affected persons as among age-matched controls resulting in a marked reduction in life expectancy." (Lang, A.E. & Lozano, A.M. Medical progress: Parkinson's Disease; First of two parts; New England Journal of Medicine, 1998; 339:1044-1063.)

Is Parkinson's contagious?

While the exact cause of the disease is not known, what is known indicates that Parkinson's is not contagious.

Does Parkinson's affect the mind?

Parkinson's is a neurological, not a mental, disorder. In the majority of cases, it slows the body, not the mind. However, when brain cells are affected by medication, some emotional changes can be expected.

Anxiety and depression are very common among people with Parkinson's and may occur due to seratonin imbalance, a side effect of certain medications. This may eventually lead to loss of memory. Anxiety and depression are difficult to diagnose in patients with Parkinson's because the symptoms are parallel to those of the disease.

Parkinsonians may also suffer from nightmares and vivid dreams that are not a result of the Parkinson's but instead, the side effects of medications.

Parkinson's medication, which controls production of dopamine, may affect the person's ability to concentrate, i.e. processing two cognitive tasks simultaneously. Sleep deprivation and depression may also cause difficulty in concentrating.

Another side effect of the medication may be occasional mild hallucinations. This side effect can occur when the medication effectively controls the person's Parkinson's symptoms. The hallucinations are not frightening and the Parkinsonian is well aware they are not real. If the drugs are working well, the person may chose to live with this side effect.

Some people with Parkinson's also get dementia, but then, so do some people who do not have Parkinson's.

Tuberculosis

2007-01-19T23:33:00.000+01:00

What is tuberculosis?
Tuberculosis is a disease caused by bacteria called Mycobacterium tuberculosis. The bacteria can attack any part of the body, but they usually attack the lungs.

How is TB spread?
TB is spread through the air from one person to another. When a person with TB disease of the lungs or throat coughs, sneezes or even speaks, the TB bacteria enter the air, and people nearby might breathe in these bacteria and become infected.

When a person breathes in TB bacteria, the bacteria can settle in the lungs and begin to multiply. From there, they can move through the blood to other parts of the body, like the kidney, spine, and brain.

TB in the lungs or throat can be infectious. This means that the bacteria can be spread to other people. TB in other parts of the body usually is not infectious.

How much of a threat is TB?
According to the World Health Organization, TB infection is currently spreading at the rate of one person per second. The disease kills more young people and adults than any other infectious disease and is the world's biggest killer of women. In 1993, WHO declared TB to be a global health emergency. Each year, an estimated eight million to 10 million people contract the disease and about two million people die from it. About one-third of the world's population -- or approximately two billion people -- carry the TB bacteria but most never develop the active disease. Around 10% of people infected with TB actually develop the disease at some point during their lives, but this proportion is changing because of HIV. HIV severely weakens the human immune system and makes people much more vulnerable to TB infection.

What is latent TB infection?
Most people who become infected with TB are able to fight the bacteria and stop them from multiplying. The bacteria become inactive, but they remain alive in the body and can become active later. This is called latent TB infection. People with latent TB infection have no symptoms, cannot spread TB to others, usually have a positive skin test reaction and can develop TB disease later in life if they do not receive treatment for latent TB infection.

Many people who have latent TB infection never develop TB disease. In these people, the TB bacteria remain inactive for a lifetime without causing disease. But in other people, especially people who have weakened immune systems, the bacteria usually become active and cause TB.

What is TB disease?
TB bacteria become active if the immune system cannot stop them from multiplying. The active bacteria begin to multiply in the body and cause TB disease. Some people develop TB disease soon after becoming infected, before their immune system can fight the TB bacteria. Other people might get sick later, when their immune systems become weak for some reason.

What are some of the symptoms of TB disease?
Although people with latent TB infection do not have symptoms and cannot spread TB to others, people with active TB disease may spread TB. People with active TB disease may have an abnormal chest x-ray, a positive sputum smear or culture, and may experience some of the following symptoms:

a bad cough that lasts longer than two weeks
chest pain
coughing up blood or sputum
weakness or fatigue
weight loss
no appetite
chills
fever
sweating at night

How is TB disease treated?
TB can almost always be cured with medicine. The most common medicines used to treat TB are:

isoniazid (INH)
rifampin (RIF)
pyrazinamide (PZA)
ethambutol (EMB)
streptomycin (SM)

Treatment for TB depends on whether a person has active TB or latent TB infection. A person who has become infected with TB but does not have active TB might be given preventive therapy. Preventive therapy aims to kill TB bacteria that currently are inactive to prevent them from causing active TB disease in the future.
If a doctor decides a person should have preventive therapy, the usual prescription is a daily dose of INH. The person takes INH for six to nine months -- possibly up to a year for some patients --with periodic checkups to make sure the medicine is being taken as prescribed.

However, when a patient has active TB, several different medicines are needed. Taking several drugs together will do a better job of killing all of the bacteria and preventing them from becoming resistant to the drugs. Many medications are available in fixed-dose combinations (FDC), which combine several medications into a single tablet. WHO strongly recommends the use of FDC tablets for TB treatment.
Patients commonly receive a combination of several drugs -- most frequently INH plus two to three others -- usually for at least six months. The patient will probably notice improvements only a few weeks after starting to take the drugs.

It is very important that patients take their medicine correctly for the full length of treatment. If the medicine is taken incorrectly or treatment is stopped, the patient might become sick again and will be able to infect others with TB. If the treatment is not completed, the TB bacteria might become resistant to the medications. As a result, many public health authorities recommend DOTS, or directly observed treatment, short-course, where a health care worker ensures that patients are taking their treatment regimens properly.
Regular checkups are needed to monitor treatment progression. Sometimes the medicines used to treat TB can cause side effects. It is important that people undergoing both preventive therapy and treatment for TB disease immediately inform a doctor if they begin having any unusual symptoms.
The treatment of tuberculosis in people infected with HIV requires close monitoring. It is especially important for HIV-positive people to discuss TB treatment options with a health care worker to avoid potential complications, because some commonly prescribed medications to treat TB can interact with some antiretroviral drugs.
The standard treatment regimen for TB patients who previously have been treated for the disease also may differ. Re-treatment cases also should be closely monitored because they have a higher likelihood of drug resistance, making treatment more difficult.

What is DOTS?
Directly observed treatment, short-course, or DOTS, is the internationally recommended strategy to control TB. DOTS has five components:

political commitment to sustained TB control
access to quality-assured TB sputum microscopy
standardized short-course drug treatment, including direct observation of therapy
an uninterrupted supply of quality-assured drugs
a standardized recording and reporting system, enabling assessment of outcome in all patients.

Is there a vaccine for TB?
Bacille Calmette-Guerin vaccine currently is the only vaccine available for TB. Although this vaccine is not widely used in the United States or Northern Europe, WHO recommends that BCG be given to infants and young children in countries where TB is common. The BCG vaccine does not always protect people from TB, and it should not be given during pregnancy or to children with symptomatic HIV infection.

Although BCG appears to reduce the risk of serious childhood forms of TB, BCG does not seem to be highly effective as people move into adulthood. Efforts to develop a more effective TB vaccine are underway, and researchers hope to make such a vaccine available within a decade.

What is multidrug-resistant TB?
The TB bacteria can become resistant to a drug or several drugs used to treat the disease. Drug resistance can occur when TB patients do not adhere to their prescribed drug regimens, health professionals prescribe an incorrect treatment regimen, or an unreliable drug supply interrupts patients' treatment. This means that the drug can no longer kill the bacteria.

Drug resistance is more common in people who have spent time with someone with drug-resistant TB disease; do not take their medicine regularly; do not take all of their prescribed medicine; develop TB disease after having taken TB medicine in the past; or come from areas where drug-resistant TB is common.

Sometimes the bacteria become resistant to more than one drug. This is called multidrug-resistant TB, or MDR-TB. People with MDR-TB disease must be treated with specific drugs that often are much more expensive than conventional therapy. These drugs are not as effective as the usual drugs for TB and they might cause more side effects. In addition, some people with MDR-TB disease must see a TB expert who can closely observe their treatment to ensure it is effective.

People who have spent time with someone with MDR-TB disease can become infected with TB bacteria that are resistant to several drugs. If they have a positive skin test reaction, they might be given preventive therapy. This is very important for people who are at high risk of developing MDR-TB disease, such as children and people living with HIV.

How does TB disease develop?
There are two possible ways a person can develop TB disease. The first applies to a person with latent TB infection -- when a person might have been infected with TB for years but has otherwise been healthy and without symptoms. However, it is possible for latent TB infection to become active at any time, particularly if a person's immune system is weakened. In this way, a person might become sick with TB disease months or even years after they first breathed the TB bacteria.

The other way TB disease develops happens much more quickly. Sometimes when a person first breathes in the TB bacteria the body is unable to protect itself against the disease. The bacteria then develop into active TB disease within weeks.

What is the TB skin test?
The TB skin test is one way to determine if a person has TB infection. Although there is more than one TB skin test, the preferred TB skin test is the Mantoux test, which also is called the PPD skin test.

For this test, a small amount of testing material is placed just below the top layers of skin, usually on the arm. Two to three days later, a health care worker checks the arm to see if a bump has developed and measures the size of the bump. If the bump is of a certain size then the person is presumed to have TB infection.

Because a TB skin test cannot distinguish between latent TB infection and active TB disease, a health care worker will want to determine if the person has active TB disease. This is done by using several other tests, including a chest X-ray and a test of a person's mucus coughed up from the lungs.

TB often is more difficult to diagnose in HIV-positive people than in HIV-negative people. The skin test might not be a reliable way to determine if people living with HIV/AIDS have TB. For HIV-positive people, chest X-rays and sputum cultures are recommended to determine if they have active TB. It also is recommended that HIV-positive people receive a skin test every six to 12 months, depending on their risk of coming into contact with TB bacteria.

What are the links between HIV and TB?
HIV/AIDS and TB are so closely connected that the terms "co-epidemic" or "dual epidemic" often are used to describe their relationship. The dual epidemic often is called TB/HIV or HIV/TB. HIV affects the immune system and increases the likelihood that people will acquire new TB infection. HIV also can facilitate both the progression of latent TB infection to active disease and relapse of the disease in previously treated patients. TB is one of the leading causes of death in HIV-positive people.

How many people are co-infected with TB and HIV?
An estimated 33% of the 40 million people living with HIV/AIDS worldwide are co-infected with TB. Furthermore, without proper treatment, approximately 90% of people living with HIV/AIDS die within months of contracting TB. The majority of people who are co-infected with both diseases live in sub-Saharan Africa.

What is the impact of co-infection with TB and HIV?
Each disease speeds up the progress of the other, and TB considerably shortens the survival time of people living with HIV/AIDS. TB kills up to half of all AIDS patients worldwide. People who are co-infected with HIV and TB are up to 50 times as likely to develop active TB in a given year as people who are HIV-negative.

HIV infection is the greatest risk factor for the progression of latent TB into active TB, and TB bacteria can accelerate the progress of HIV.

Many HIV-positive people in developing countries develop TB as the first sign of the later stages of the disease. The two diseases represent a deadly combination because they are more destructive together than either disease alone:

TB is harder to diagnose in HIV-positive people.
TB progresses faster in HIV-positive people.
TB in HIV-positive people is almost certain to be fatal if undiagnosed or left untreated.
TB occurs earlier in the course of HIV infection than many other opportunistic infections.

What is the impact of TB/HIV on women?
Women worldwide bear a disproportionate burden of poverty, poor health, malnutrition and disease. TB causes more deaths among women than all causes of maternal mortality combined, and more than 900 million women are infected with TB worldwide. This year, one million women will die and 2.5 million women -- mainly between the ages of 15 and 44 -- will become sick from the disease.

Once infected with TB, women of reproductive age are more susceptible to developing active TB than men of the same age. Women in this age group also are at greater risk of contracting HIV. As a result, in certain regions, young women ages 15 to 24 with TB outnumber young men of the same age with the disease.

While poverty is the underlying cause of many TB cases in rural areas, poverty also is aggravated by the impact of TB. In 1996, a study by the World Bank, World Health Organization and Harvard University reported TB was a leading cause of "healthy years lost" among women of reproductive age.

Alzheimer's Disease

2007-01-17T00:00:00.000+01:00

What treatments are available?

Currently, there is no known treatment that will cure Alzheimer's disease (AD). Many research programs, however, are pursuing promising studies focused on halting or preventing the disease process completely. For those who are currently suffering with AD, there are medications that can help control symptoms of the disease. In addition, medication treatments are also available to help manage agitation, depression, or psychotic symptoms (hallucinations or delusions), which may occur as the disease progresses.
FDA-Approved Drugs

There are five FDA-approved drugs that can control symptoms and slow the progression of AD. Cognex* (tacrine), Aricept (donepezil), Exelon (rivastigmine), and Razadyne** (galantamine) slow the metabolic breakdown of acetylcholine, and make more of this brain chemical available for communication between cells. It has been known for some time that those suffering from AD have low levels of acetylcholine (an important brain chemical involved in nerve cell communication). This helps slow the progression of cognitive impairment and can be effective for some patients with AD. All of the medications mentioned above are approved for the treatment of mild to moderate symptoms of Alzheimer’s disease; however, in 2006, the FDA approved Aricept for the management of severe AD symptoms based on several clinical trials. Namenda (memantine) was the first drug approved for the treatment of moderate to severe AD. Namenda is an NMDA receptor antagonist, and appears to protect the brain's nerve cells against excess amounts of glutamate, a messenger chemical released in large amounts by brain cells that are damaged by pathological processes associated with AD.

*Cognex, though effective, has more adverse side effects than the other medications in this category.

**Janssen-Ortho Inc. renamed Reminyl to Razadyne in April of 2005. The name was changed to help avoid confusion with the diabetes drug Amaryl, which is marketed by Sanofi-Aventis.
Medications that can control depression, anxiety, and psychotic symptoms:

Medications that can control depression, anxiety, and psychotic symptoms can help patients in the middle stages of AD. The medications prescribed for these symptoms are not specifically designated for AD, but they may be considered as part of the treatment plan by the supervising physician(s). Aggression, hyperactivity, and combativeness are all examples of agitated behavior. Psychotic behavior may include paranoid thoughts, delusions, or hallucinations. Generally, medications for these symptoms are considered when non-medication alternatives have failed and/or these symptoms put the AD patient, or others, in danger.
Other

Antioxidants

There have been studies supporting the use of vitamin E supplements in the management of AD; however, other research has produced conflicting results. Further rigorous scientific research will help clarify this issue. There are ongoing clinical trials investigating whether the progression of AD can be slowed by taking vitamins E and C. Another clinical trial is examining whether AD or cognitive decline can be prevented by taking vitamin E and/or selenium.

In April of 2005, the results of multicenter study comparing vitamin E; Aricept (donepezil), an AD treatment drug; and placebo for delay or prevention of progression to Alzheimer’s disease in patients with mild cognitive impairment were published in the New England Journal of Medicine. Mild cognitive impairment is a transitional stage between the forgetfulness of normal aging and the more serious memory decline and other problems associated with AD. The results of the study indicated that Vitamin E had no effect on slowing the progression to AD over the course of the study. Further research will help clarify the role of vitamin E and other antioxidants for delaying or preventing the progression to AD.

Estrogen

Research findings have suggested that estrogen may protect the brain in women taking this hormone to help manage the symptoms of menopause. Therefore, scientists also were interested in finding out if estrogen could slow the progression of Alzheimer’s disease or reduce its risk. Clinical trials with patients already diagnosed with Alzheimer’s disease, did not show that estrogen had any impact on the progression of the disorder. One study determined that older woman using estrogen had an increase risk of developing dementia, and women over age 65 who used progestin with estrogen had an increased risk of dementia. Based on the these findings, the U.S. Food and Drug Administration recommends that women who choose to use hormone therapy (either estrogen alone or progestin plus estrogen) to help prevent osteoporosis, hot flashes or vaginal dryness, should take the medication for the shortest period of time at the lowest dose possible to provide relief. When calculated for a large population of women, the increased risk of dementia from combination hormone therapy is significant; however, the risk to any individual older woman is actually relatively small. Nonetheless, women of any age should consult with a physician about their individual risks and benefits if they are taking or considering implementing hormone replacement therapy.

NSAIDs (non-steroidal anti-inflammatory drugs)

Studies suggest that brain inflammation may play a role in Alzheimer’s disease damage, and that nonsteroidal anti-inflammatory drugs (NSAIDs) could potentially slow the progression of the disease. However, human clinical trials have not shown that these medications are beneficial. For example, in patients who already have Alzheimer’s, naproxen (Aleve) and rofecoxib (Vioxx) did not delay disease progression. Another clinical trail was examining whether celecoxib (Celebrex) and naproxen could prevent Alzheimer’s disease in older healthy people at risk for this disease. The trial was stopped because the data indicated an apparent increase in cardiovascular and cerebrovascular events among the participants taking naproxen when compared with those on placebo. This step was taken as a precautionary measure to ensure the safety of the study’s participants. Researchers are continuing to explore the role of other anti-inflammatory drugs in the treatment or prevention of Alzheimer’s disease.

Ginkgo biloba

Ginkgo biloba is an extract made from the leaves of the ginkgo tree, and some studies have suggested that the extract may help in treating symptoms of Alzheimer’s disease. While there is no evidence that ginkgo biloba will prevent or cure Alzheimer’s disease, there is an ongoing clinical trial that will help determine if it can prevent dementia or delay cognitive decline in older people.

A thoughtful evaluation must be performed by a physician before taking any medications, over-the-counter drugs, supplements, or herbs. The American Health Assistance Foundation does not endorse any of these medications, vitamins, or herbs. A qualified physician should make an informed decision based on each person's medical history and current prescriptions.

Are there drugs that can delay the onset of Alzheimer's disease?

Aricept (donepezil), an Alzheimer's disease treatment drug appears to have a slowing effect—though limited—on the progression from mild cognitive impairment to Alzheimer's disease, according to a study published in the April, 2005 edition of the New England Journal of Medicine. These patients had the memory-related variety of mild cognitive impairment, a transitional stage between the forgetfulness of normal aging and the more serious memory decline and other problems associated with Alzheimer's disease. Over the first year of the three-year trial, mild cognitive impairment patients treated with Aricept had a reduced risk of progressing to Alzheimer's disease compared to patients who took placebo, an inactive pill. The study found the effect of the Aricept treatment lasted longer (up to two to three years) in those patients carrying the ApoE4 gene. Previous studies have shown those with the ApoE4 gene have a higher propensity to develop Alzheimer's than the general population. The findings of this study open the door for discussion of donepezil treatment on an individual basis for patients with mild cognitive impairment. Source: Mayo Clinic, Rochester and the National Institute on Aging

Is Alzheimer's disease hereditary?

Familial Alzheimer’s disease (FAD) is a rare form of the disease, affecting less than 10 percent of Alzheimer’s disease patients. All FAD is early-onset, meaning the disease develops before age 65. It is caused by gene mutations on chromosomes 1, 14, and 21. Even if one of these mutated genes is inherited from a parent, the person will almost always develop early-onset Alzheimer’s disease. All offspring in the same generation have a 50/50 chance of developing FAD if one of their parents had it.

The majority of Alzheimer’s disease cases are late-onset, usually developing after age 65. Late-onset Alzheimer’s disease has no known cause and shows no obvious inheritance pattern. However, in some families, clusters of cases are seen. Although a specific gene has not been identified as the cause of late-onset Alzheimer’s disease, genetic factors do appear to play a role in the development of this form of the disease. The ApoE gene on chromosome 19 has three forms—ApoE2, ApoE3 and ApoE4. Studies have shown that people who inherit the E4 version of the gene are more likely to develop the late-onset form of Alzheimer’s disease. Scientists estimate that an additional four to seven genes influence the risk of developing late-onset Alzheimer’s disease. Two of these genes are UBQLN1 and SORL1, which are located on chromosomes 9 and 11, respectively.

Genetic risk factors alone are not enough to cause the late-onset form of Alzheimer’s disease, so researchers are actively exploring education, diet, and environment to learn what role they might play in the development of this disease.

What are the stages of Alzheimer's disease?

There are three general stages of Alzheimer's disease:

Stage 1: Early in the illness, Alzheimer's patients tend to have less energy and spontaneity, though often no one notices anything unusual. They exhibit minor memory loss and mood swings, and are slow to learn and react. After a while they start to shy away from anything new and prefer the familiar. Memory loss begins to affect job performance. The patient is confused, gets lost easily, and exercises poor judgment.

Stage 2: In this stage, the Alzheimer's victim can still perform tasks independently, but may need assistance with more complicated activities. Speech and understanding become slower, and patients often lose their train of thought in mid-sentence. They may also get lost while traveling or forget to pay bills. As Alzheimer's victims become aware of this loss of control, they may become depressed, irritable an restless. The individual is clearly becoming disabled. The distant past may be recalled, while recent events are more difficult to remember. Advancing Alzheimer's has affected the victim's ability to comprehend where they are, the day and the time. Caregivers must give clear instructions and repeat them often. As the Alzheimer's victim's mind continues to slip away, the patient may invent words and not recognize familiar faces.

Stage 3: During the final stage, patients lose the ability to chew and swallow. The very essence of the person is vanishing. Memory is now very poor and no one is recognizable. Patients lose bowel and bladder control, and eventually need constant care. They become vulnerable to pneumonia, infection and other illnesses. Respiratory problems worsen, particularly when the patient becomes bedridden. This terminal stage eventually leads to death.

Who should I go to if I suspect Alzheimer's disease?

First, go to your regular family physician. The physician will probably do a variety of tests to determine if you have probable Alzheimer's. Neurologists, gerontologists, and geriatric psychiatrists may also become part of the patient's treatment team.

What kind of information should I bring to my first visit to the doctor?

Bring any medical records you have and a list of the medicines you are currently taking to your first visit. If you don't know the names of the drugs, bring the pill bottles with you. A medication or a combination of medications can sometimes cause symptoms that resemble Alzheimer's disease. It's a good idea to make a list of symptoms or behaviors in yourself or your loved one that you're concerned about and give it to your doctor.

What are the diagnostic tests used in Alzheimer's disease?

The term “dementia” refers to a progressive deterioration of intellectual functions due to a brain disease, organ failure, toxins, or other causes. In western countries, Alzheimer’s disease (AD) accounts for more than half of dementia cases.

At present, the only way to diagnose AD definitely is to perform a brain autopsy. If the patient exhibited Alzheimer-like symptoms while alive and the brain tissue contains the microscopic abnormalities typical of AD, then a definitive diagnosis of AD can be made. While the patient is alive, physicians can correctly diagnose AD about 90 percent of the time based on mental and behavioral symptoms, a physical examination, neuropsychological tests, and laboratory tests.

The physician first takes a history of mental and behavioral symptoms, using information provided by the patient and the family. In nearly 75 percent of cases, AD starts with the inability to remember recent events and to learn and retain new information. Early stage AD patients experience memory problems that interfere with daily living and that become steadily worse.

Other early AD symptoms can include difficulty with managing money, driving, orientation, shopping, following instructions, abstract (conceptual) thinking, and finding the right words. There may also be other problems, such as poor judgment, emotional instability, and apathy. AD can be distinguished from other causes of dementia in part by the symptoms exhibited, the extent to which these symptoms occur, and the speed with which the disease progresses.

Neuropsychological tests identify behavioral and mental symptoms that are associated with brain injury or abnormal brain function. Determining which of the many neuropsychological tests to use with a particular patient depends on the symptoms the patient is exhibiting and how far advanced the dementia is. Usually, physicians start with a brief screening tool, such as the Mini-Mental Status Examination (MMSE), to help confirm that the patient is experiencing problems with intellectual functions. The MMSE includes tests of memory, attention, mathematical calculation, and language. In another section, the patient copies a design, such as intersecting pentagons.

If a patient has severe dementia, further neuropsychological testing beyond the MMSE and perhaps another screening tool is usually not necessary. However, for patients with mild intellectual deficits, more tests may be needed to determine whether the patient is simply showing signs of advanced age or is developing AD. The patient may be referred to a neuropsychologist, who will administer a battery of tests to identify deficits more specifically.

A number of different laboratory tests can be performed in order to help identify the cause of dementia, although the American Academy of Neurology (AAN) recommends routine use of only three tests. One is the thyroid function test, which measures blood levels of hormones secreted by the thyroid, a gland located in the neck. A condition known as hypothyroidism, in which the thyroid fails to produce sufficient thyroid hormones, is common in the elderly and, in some cases, can cause dementia. Another test involves measuring the level of vitamin B12 in the blood. Vitamin B12 deficiency is also common in the elderly and can cause dementia.

Finally, the AAN recommends a brain scan, using computed tomography or structural magnetic resonance imaging. This can rule out other possible causes of dementia, including brain tumors, stroke, blood accumulation on the brain surface, or other conditions. In addition, the appearance in the brain scan of characteristic structural changes that occur in the brains of AD patients can lend support to an AD diagnosis.

Using the patient’s history of symptoms and the results from the physical examination, neuropsychological tests, and laboratory tests, the physician can accurately diagnose AD in 9 out of 10 cases.

How long does Alzheimer's disease last on average?

On average, patients with Alzheimer's disease live for 8 to 10 years after they are diagnosed. It can last as long as 20 years, and always ends in death.

Is there a genetic test to see if you have a predisposition to Alzheimer's?

A blood test is available to identify which ApoE alleles a person has, because apolipoprotein is associated with an already well-studied condition, heart disease. However, this blood test cannot tell people whether they will develop Alzheimer's or when. Although some people want to know whether they will get Alzheimer's disease later in life, this type of prediction is not yet possible. In fact, some researchers believe that apoE tests or other screening measures may never be able to predict Alzheimer's with 100% accuracy.

Is there a connection between Alzheimer's disease and aluminum? Should I get rid of my aluminum pots and pans?

Metals have been implicated in neurodegenerative diseases, although it is unlikely that they are the sole cause for any of them. Interest in a possible connection between aluminum and Alzheimer's disease arose when autopsies of the brains of Alzheimer's patients revealed higher than normal concentrations of aluminum. The toxicity of aluminum has been the subject of much controversy in the past few decades. Although it is generally believed that the metal is harmless to human health, a role for aluminum in Alzheimer's disease has been suggested. The exact mechanism of aluminum toxicity is not known and a direct causal role has not been determined. Many scientists believe that the buildup of aluminum in the brain of Alzheimer's patients is the result of damage to nerve cells, rather than the cause of this damage. Some studies have even suggested that the processing of the brain tissue at autopsy may artificially raise aluminum levels. However, there is some evidence showing that aluminum compounds may increase the formation of agents called reactive oxygen species. These substances, which are constantly formed in the human body, have been shown to damage proteins and play a role in various diseases. In relation to Alzheimer's disease, these compounds may play an important role in nerve cell damage. Aluminum is also known to alter the activity of several key enzymes in the central nervous system. Further, there are also some studies showing elevated risk of Alzheimer's disease in areas where there is high concentration of aluminum in drinking water. This is in contrast to many studies examining antacid exposure and Alzheimer's disease that have been largely negative (antacids contain thousands of times more aluminum than the amounts taken in through drinking water). Exposure to aluminum from cooking utensils, baking powder, deodorants, or antacids is not sufficient to cause the disease. In total, these studies provide some evidence that potential links between aluminum and Alzheimer's disease exist, but this area requires continued research efforts.

What is the cost of Alzheimer's disease?

In terms of health care expenses and lost wages of both patients and their caregivers, the cost of Alzheimer's disease nationwide is estimated to be $100 billion per year. The yearly cost of caring for one Alzheimer's patient ranges from $18,400 to $36,100 depending on how advanced the disease is.. The average direct cost of caring for an Alzheimer's patient from diagnosis to death is $174,000. According to MetLife market surveys, on average, home health aides cost $19 per hour, the annual cost for an assisted living facility is $34,860, and the daily cost of a private room in a nursing home is $203, which calculates to $74,095 per year.*

Is Alzheimer's covered by Medicare/Medicaid?

Medicare is a federal health insurance program for people age 65 or older who are receiving Social Security retirement benefits. There are specific eligibility requirements in order for a person to receive assistance from this program. Medicare covers some, but not all, of the services a person with Alzheimer's disease may require. Medicaid is a federal program for certain individuals and families with low incomes and resources, administered by each state, so eligibility and benefits vary from state to state. The program is typically administered by a state agency. Medicaid can cover all or a portion of nursing home costs. A person with Alzheimer's can qualify for long-term care only if he has minimal income and cash assets. Medicaid may be applied for by calling your state's Department of Human Services or Medicaid Assistance Program.

Are memory problems an indication of Alzheimer's disease?

Mild forgetfulness and memory delays often occur as part of the normal aging process. Older individuals simply need more time to learn a new fact or to remember an old one. We all have occasional experiences when it is difficult to remember a word or someone's name; however, those afflicted with Alzheimer's disease (AD) will find these symptoms progressing in frequency and severity. Everyone, from time to time will forget where they placed their car keys; an individual with AD, however, may not remember what the keys are for.

There has been recent interest in a condition called Mild Cognitive Impairment (MCI), which consists of pronounced forgetfulness, but not dementia and has recently been identified as a major risk factor for developing AD. While all patients who develop some form of dementia go through a period of MCI, not all patients exhibiting MCI will go on to develop AD.

There are many conditions that may contribute to the development of memory problems and dementia; AD is just one of them. A decline in intellectual functioning that significantly interferes with normal social relationships and daily activities is characteristic of dementia, of which AD is the most common form. AD and multi-infarct dementia (a series of small strokes in the brain) cause the vast majority of dementias in the elderly. Other possible causes of dementia-like symptoms include infections, drug interactions, a metabolic or nutritional disorder, brain tumors, depression, or another progressive disease like Parkinson's disease.

If memory loss increases in frequency or severity, makes an impression on friends and family, begins to interfere with daily activities (employment tasks, social interactions, and family chores, for example), it is advisable to seek out qualified professional advice. A physician with extensive knowledge, experience, and interest in dementia and memory problems should be involved in the evaluation process.

Malaria

2007-01-14T19:05:00.000+01:00

Q>What exactly is Malaria?

Malaria is a common and serious tropical disease. It is a protozoal infection transmitted to human beings by mosquitos biting mainly between sunset and sunrise. Human malaria is caused by four species of Plasmodium protozoa: Plasmodium falciparum, P.vivax, P. ovale and P.malariae.

Malaria is a public health problem in over 100 countries worldwide, inhabited by some 40% of the world population, i.e. over 2 billion people. It has been estimated that the incidence of malaria in the world may be in the order of 300 million clinical cases each year. Countries in tropical Africa account for more than 90% of these. Malaria mortality is estimated at almost 1 million deaths worldwide per year. The vast number of malaria deaths occur among young children in Africa, especially in remote rural areas with poor access to health services. Other high risk groups include women during pregnancy, and non- immune travellers, refugees, displaced persons, or labour forces entering into endemic areas.

Q>What varieties of Malaria are known to exist?

In total there are nearly 120 species of Plasmodia, including at least 22 found in primate hosts, and 19 in rodents, bats and other mammals. About 70 other Plasmodia species have been described in birds and reptiles. Human malaria is caused by four species of Plasmodium: Plasmodium falciparum, P.vivax, P. ovale and P.malariae.

Various strains may exist within well-defined species, based on biological variations from one geographical area to another.

Q>How do the known varieties differ?

The zoological classification of the almost 120 Plasmodium species is too complex to detail here. The 4 species causing human malaria differ morphologically, immunologically, in geographical distribution, relapse pattern, drug response, etc. Plasmodium falciparum causes the most serious disease.

Q>What are the symptoms?

The classic clinical course of malaria consists of bouts of fever accompanied by other symptoms and alternating with periods of freedom from any feeling of illness. The intermittent type of fever is usually absent at the beginning of the disease, when headache, malaise, fatigue, nausea, muscular pains, slight diarrhoea and slight increase of body temperature are the predominant and vague symptoms, often mistaken for influenza or a gastro-intestinal infection. Most severe forms of the disease result in organ failure, delirium, impaired consciousness and generalized convulsions, followed by persistent coma and death.

Q>How long is the incubation period/onset of symptoms?

The incubation period in malaria covers the time between infection and the first appearance of clinical signs, of which fever is the most common. The length of the incubation period is usually between 9 and 30 days, depending on the infecting species (shortest for P.falciparum, longer for P.malariae). In some strains of P.vivax (P.v.hibernans) the incubation period may last some 8-9 months.

falciparum malaria, which can be fatal, must always be suspected if fever, with or without other symptoms, develops at any time between one week after the first possible exposure to malaria and two months (or even longer in exceptional cases) after the last possible exposure.

Q>Which parts of the body does it usually infect (at both the organic & cellular levels)?

Parasites (sporozoite stage) are injected into the skin capillaries by a mosquito. From there they travel via the bloodstream to the liver, where they develop and multiply in liver cells before entering the blood stream again (merozoite stage) and invading for further reproduction. From there other internal organs, e.g. the brain, can be affected as clumps of heavily infected erythrocytes start blocking capillary blood flow.

Q>How is it transmitted?

Malaria is most commonly transmitted through the bite of an infected anopheline mosquito. Of the approximately 400 species of Anopheles throughout the world, only about 60 are vectors of malaria under natural conditions, some 30 of which are of major importance.

Malaria can also be transmitted by blood transfusion, and by contaminated needles and syringes.

In congenital malaria, parasites are transmitted from mother to child before and/or during birth.

Q>Can an infected person transmit Malaria to others before symptoms appear?

Malaria parasites are normally transmitted from one person to another via mosquitos of the Anopheles species. The form of the parasite that can infect mosquitos is called gametocyte. Gametocytes start developing in capillaries of the inner organs of infected persons after the invasion of the blood by merozoites. Mature gametocytes, which are infective to mosquitos, appear in the peripheral blood some 3 (in the case of P.vivax) to 10 days (P.falciparum and P.malariae) later. The female Anopheles mosquito ingests malaria gametocytes when it takes a blood meal from an infected person. The parasite then needs a period of development in the mosquito before it can infect other people again. The length of this period (sporogonic cycle) depends on the Plasmodium species and the ambient temperature.

In highly endemic areas, such as in parts of Africa, persons who have been repeatedly infected with malaria acquire a degree of immunity to malaria which suppresses most clinical symptoms. These people may carry gametocytes in their blood that will infect the mosquitos biting them. In non-immunes, clinical symptoms will usually have developed before gametocytes appear in the peripheral bloodstream.

Malaria infected persons who donate blood before the onset of clinical symptoms, but after merozoites have entered the blood stream from the liver, can unknowingly transmit malaria through their blood donation. Blood donations from (semi)immune persons without clinical symptoms may also contain malaria parasites. Similarly, malaria may be transmitted by contaminated needles and syringes.

Q>For how long is a patient infectious to others after onset of symptoms?

In P.vivax and P.ovale infections the patient is practically immediately infectious to mosquitos after the onset of symptoms. In P.falciparum infections only after several days, when mature gametocytes appear in the peripheral bloodstream.

Antimalarial drugs such as chloroquine and mefloquine that are given to cure malaria infections do not eliminate mature Plasmodium falciparum gametocytes from the bloodstream. A person who has been successfully treated with antimalarial drugs may thus be healthy but infective for several weeks until the gametocytes die off naturally.

Q>Can a survivor transmit Malaria to others after she or he has fully recovered?

Yes, as an asymptomatic carrier of a malaria infection. Examples are people who have built up immunity to falciparum malaria (see above), or people who, after having recovered from the primary attack of P.vivax or P.ovale infections, subsequently suffer a relapse.

Antimalarial drugs such as chloroquine and mefloquine that are given to cure malaria infections do not eliminate mature Plasmodium falciparum gametocytes from the bloodstream. A person who has been successfully treated with antimalarial drugs may thus be healthy but infective for on average 2 months until the gametocytes die off naturally, or until another drug such as primaquine is given that does eliminate the gametocytes.

Q>Is it airborne?

Not in the usual sense of the word. However, mosquitos do fly, of course, and malaria-carrying female anophelines fly through the air to reach the source of blood needed to feed on and develop their eggs.

Anopheles mosquitos are not usually found more than 2 or 3 kilometres from their breeding places in any large number. However, strong seasonal winds may carry Anopheles up to 30 km from their main breeding place.

Occasionally malaria has been transmitted near airports in non-endemic areas, by mosquitos that were carried in on aircraft coming from endemic zones.

Q>How do I avoid catching it?

Protection from biting mosquitos is the first line of defense against malaria in endemic areas. The following measures are effective in reducing the risk of mosquito bites:

* If possible, avoid going out between dusk and dawn when mosquitos commonly bite.
* Wear long-sleeved clothing and long trousers when going out at night, and avoid dark colours, which attract mosquitos.
* Apply insect repellent to exposed skin, choosing one with DEET or dimethyl phthalate.
* Stay in a well-constructed and well-maintained building in the most developed part of town.
* Use screens over doors and windows. If accommodation allows entry of mosquitos, use a mosquito net over the bed.
* Use anti-mosquito sprays or insecticide dispensers that contain tablets impregnated with pyrethroids, or burn pyrethroid mosquito coils in bedroom at night.

In addition, malaria prophylaxis may be prescribed to protect against clinical symptoms. The type of prophylaxis depends on the area, local species of malaria, local pattern of antimalarial drug resistance, and personal characteristics such as allergies and contraindications, including (for some drugs) pregnancy. Contact your physician about the exact prophylaxis that would be suitable for you.
No antimalarial prophylaxis regimen gives complete protection. Malaria may be contracted despite taking antimalarial prophylaxis.

In general, pregnant women and parents travelling with young children should weigh the necessity of the trip when travelling to areas where malaria parasites have become highly resistant to chloroquine.

Q>What is the basic treatment?

Treatment is a function of the infecting species, the degree of drug-resistance, the severity of infection, and personal allergies and contraindications. More information is available in publications such as International Travel and Health - vaccination requirements and health advice by the World Health Organization, Geneva.

Q>Is there any cure or vaccine?

Adequately and promptly treated, malaria is a curable disease.

Various approaches to a malaria vaccine are under current study, but none is expected to be comercially available anytime soon.

Q>Can blood from survivors be used to make a serum?

There is no need as effective drugs are available.

Q>Does survival confer subsequent immunity?

Only partially and for a duration that is a function of the intensity and frequency of prior infections. In areas with seasonal or epidemic malaria where disease is infrequent, adequate protective immunity may never build uP. In endemic areas with high levels of transmission, newborn children are protected in their first months of life by the antibodies of their immune mothers. After that they gradually develop their own immunity over the years, if they do not die from the disease. The immunity is reversible, and fully "immune" adults who leave malarious areas are known to return to a state of non-immunity over a period of 1 to 2 years.

In persons with sickle cell anaemia or the sickle cell trait, the abnormal haemoglobin S offers some protection against Plasmodium falciparum infection.

Q>If Malaria can recur in a survivor (i.e. remain latent as opposed to a second infection), how does this occur?

Reinfection is aways a possibility in endemic areas.

P.vivax and P.ovale can remain quiescent in the liver for many months. Relapses caused by the persistent liver forms may appear months, and occasionally up to 4 years after exposure. Untreated or partially treated blood infection with P.malariae may be present for many years before giving rise to a symptomatic episode, and can be carried for a lifetime.

In areas with emerging drug-resistant P.falciparum, recrudescences of the infection may occur up to a month or more after what initially seemed to be a successful clinical cure of the infection.

Q>Are there past illnesses of unknown cause that have since been identified as Malaria?

Perhaps in the far past. References to seasonal and intermittent fevers exist in the ancient Assyrian, Chinese and Indian religious and medical texts, but their true identity with malaria is uncertain. Hippocrates was the first in the fifth century B.C. to describe in detail the clinical picture of malaria and some complications of the disease.

Q>Geographically, where has Malaria been known to occur?

The boundaries of malaria transmission are determined by the presence and abundance of anophelines, their susceptibility to malaria infection, the type of hosts they select for blood meals, and whether they live long enough to serve as effective transmitters of infection, which in turn is largely determined by ambient temperature and humidity. Although currently largely confined to what today would be considered tropical conditions, in the past, malaria (P.malariae and P.vivax) was epidemic as far north as Finland.

Q>What has caused Malaria epidemics to end in past occurences?

Malaria epidemics, if uncontrolled, follow a natural course:

1. The epidemic grows in a series of steps representative of the incubation interval (the period between the occurrence of infective gametocytes in the primary case and their reappearance in a secondary case), which is about 20 days for P.vivax and 35 days for P.falciparum. The length of the incubation interval and the degree of the reproduction rate determine the rate of multiplication of transmission, which is much faster in P.vivax epidemics than in those due to P.falciparum. In areas where both P.vivax and P.falciparum are present, the initial stages of an epidemic will thus be determined by a predominance of P.vivax infections and a very gradual increase in severity of the epidemic, while in later stages P.falciparum is likely to be abundant.
2. The peak of new infections due to a P.falciparum epidemic will only be reached when roughly 50 percent of the population at risk is infected, unless climatic changes (notably colder temperatures) prevent further transmission.

Control of a malaria epidemic involves relieving the immediate clinical consequences, preventing the progress of the epidemic (in time and space), and preventing future recurrences of the epidemic. This means improving disease management and providing some form of transmission control.

Q>What are the conditions that would lead to a major epidemic?

Epidemics occur when non-immune and partially-immune populations are exposed to high rates of innoculation. Potential epidemic situations can to a large extent be identified by combining some basic knowledge of the malaria situation in an area with general aspects of the geography, history and socio-economic situation. Potential epidemic situations include:

* areas of unstable malaria where conditions for malaria transmission are marginal in terms of altitude, rainfall patterns or temperature
* areas where the level of endemic malaria has been reduced and the malaria situation has become unstable after mass drug administration and/or vector control programs, which can no longer be sustained
* situations where non-immunes migrate into an endemic area. This would include refugee movements, and migration of labour forces into endemic areas
* situations where persons harbouring malaria parasites migrate into a non-endemic, but receptive area. Receptivity refers to an abundant presence of anopheline vectors and/or the existence of other ecological and climatic factors favouring malaria transmission.

The size and impact of potential epidemics can only to a lesser extent be foreseen. Insufficient coverage of the population by health care services will exacerbate the impact.

In situations where a potential for malaria epidemics has been identified, responsible health services should be prepared to counter a beginning epidemic rapidly. Updated contingency plans should be at hand. At present many epidemic prone situations will, by their nature, stretch across national boundaries. Effective inter-country collaboration and sharing of experiences are paramount in developing emergency plans and preparing for adequate epidemic control measures.

Q>How can Malaria be controlled?

The goal of malaria control is to prevent mortality and reduce morbidity and social and economic losses, through the progressive improvement and strengthening of local and national capabilities. Four basic technical elements of the malaria control strategy are:

* to provide early diagnosis and prompt treatment
* to plan and implement selective and sustainable preventive measures, including vector control
* to detect early, contain or prevent epidemics
* to strengthen local capacities in basic and applied research to permit and promote the regular reassessment of a country's malaria situation, in particular the ecological, social and economic determinants of the disease.

Effective implementation of the malaria control strategy requires:

* sustained political commitment from all levels and sectors of government
* malaria control to be an integral part of health systems, and be coordinated with relevant development programmes in non-health sectors
* communities to be full partners in malaria control activities
* mobilization of adequate human and financial resources.

Q>Are there international regulations concerning Malaria?

International measures relating to malaria (source: Benenson, A.S. (ed.), Control of Communicable Diseases in Man, 15th edition, APHA, 1990. p269): (1) Disinsectization of aircraft before departure or in transit using a space- spray application of an insecticide of a type to which the vectors are susceptible. (2) Disinsectization of aircraft, ships and other vehicles on arrival if the health authority at the place of arrival has reason to suspect importation of malaria vectors. (3) Enforce and maintain rigid antimosquito sanitation within the mosquito flight range of all ports and airports. (4) In special circumstances, administer antimalarial drugs to potentially infected migrants, refugees, seasonal workers, and persons taking part in periodic mass movement into a areas or country where malaria has been eliminated. (5) Malaria is a Disease under Surveillance by WHO, as it is considered an essential element of the world strategy of primary health care. National health administrations are expected to notify WHO twice a year of: those areas originally malarious with no present risk of infection, those malaria cases imported into areas in the maintenance phase of eradication, those areas with chloroquine resistant strains of parasites, and those international ports and airports free of malaria.

Q>Is quarantine required or permitted as a preventive measure?

No.

Q>Is isolation required for the patient?

No.

Q>Is vaccination required or recommended for international travel?

No vaccine is available.

Q>What is the name of the infectious agent?

Plasmodium, a protozoa of which there are four species infecting humans: Plasmodium falciparum, P.vivax, P. ovale and P.malariae.

Q>When was it identified?

In 1880, Laveran, a French army surgeon in Algeria, first saw and described malaria parasites in the red blood cells of man.

Q>What is known of its genetic history?

According to Bruce-Chwatt in Essential Malariology (page 1):

Prehistoric man in the Old World was subject to malaria. it is probable that the disease originated in Africa, which is believed to be the cradle of the human race. Fossil mosquitos were found in geological strata 30 million years old and there is no doubt that they have spread the infection through the warmer regions of the globe, long before the dawn of history. Malaria followed in the wake of human migrations to the Mediterranean shores, to Mesopotamia, the Indian peninsula and South-East Asia. How malaria established itself in the New World is subject to speculation, as no reliable historical or other data exist on this point. It is possible that Plasmodium vivax and P.malariae were brought in from South-East Asia by early trans-Pacific voyages, while P.falciparum is of post-Colombian origin, through the African slaves brought by the Spanish colonisers of Central America.

Q>How is it detected?

The clinical diagnosis of malaria is difficult under the best of circumstances. Definite diagnosis is based on light microscopic observation of parasites in the red blood cells of the patient. Newer, less widely used diagnostic tools include fluorescent staining, genetic probes, and antigen detection in the form of a dip stick.

Q>What is its rate of reproduction?

The rate of reproduction of malaria is the estimated number of secondary malaria infections potentially transmitted within a susceptible population from a single non-immune individual. This number represents the theoretical estimate of the intensity of transmission. In practice transmission will depend on the parasite species involved, fluctuations of the source of infection (gametocyte carriers), the density and infectivity of the Anopheles species involved, etc.

Factors making up the mathematical formula of the basic reproduction rate are: bites per person per night by vector population, times the expectation of infective life of the vector population, times the expectation of life of female vectors (making up the "vectorial capacity of the vector population"), times the mosquito's receptivity to infection, and the days of infectivity per case.

Q>What is the natural reservoir for Malaria?

Chimpanzees and gorillas are the natural reservoir for P. malariae.

Q>What are the vectors for Malaria?

Anopheles mosquitos. Of the approximately 400 species of Anopheles throughout the world, only about 60 are vectors of malaria under natural conditions, some 30 of which are of major importance.

Q>What are some comprehensive sources of information on this disease?

* Wernsdorfer, W.H. and McGregor, Sir I., Malaria - Principles and Practice of Malariology, 2 volumes, published in 1988 by Churchill Livingstone, New York, USA.
* Bruce-Chwatt, L.J., Essential Malariology. Second edition published 1985 by William Heinemann Medical Books Ltd., London, UK.
* Originally posted to www.outbreak.org 1995.

H.I.V:- Aids

2007-01-14T18:54:00.000+01:00

1)What is HIV

HIV (human immunodeficiency virus) is the virus that causes AIDS. This virus is passed from one person to another through blood-to-blood and sexual contact. In addition, infected pregnant women can pass HIV to their baby during pregnancy or delivery, as well as through breast-feeding. People with HIV have what is called HIV infection. Most of these people will develop AIDS as a result of their HIV infection.Structure of HIV

2)What is AIDS? What causes AIDS?

AIDS stands for acquired immunodeficiency syndrome. An HIV-infected person receives a diagnosis of AIDS after developing one of the CDC-defined AIDS indicator illnesses, (opportunistic infection.) An HIV-positive person who has not had any serious illnesses also can receive an AIDS diagnosis on the basis of certain blood tests (CD4+ counts). A CD4+ count of less than 200 indicates a severely damaged immune system and an AIDS diagnosis.

A positive HIV test result does not mean that a person has AIDS. A diagnosis of AIDS is made by a physician using certain clinical criteria.

Infection with HIV can weaken the immune system to the point that it has difficulty fighting off certain infections. These types of infections are known as "opportunistic" infections because they take the opportunity a weakened immune system gives to cause illness.

Many of the infections that cause problems or may be life threatening for people with AIDS, are usually controlled by a healthy immune system. The immune system of a person with AIDS is weakened to the point that medical intervention may be necessary to prevent or treat serious illness.

Today there are medical treatments that can slow down the rate at which HIV weakens the immune system. There are other treatments that can prevent or cure some of the illnesses associated with AIDS. As with other diseases, early detection offers more options for treatment and preventative care.

Also, once a person is diagnosed with AIDS, they will always be considered to have AIDS, regardless of clinical changes later on. For example, if a person has HIV and a CD4 count below 200, they are considered to have AIDS. If their CD4 count later goes back to above 200, they are still considered to have AIDS.

3)How can I tell if I'm infected with HIV? What are the symptoms?

The only way to determine for sure whether you are infected is to be tested for HIV infection. You cannot rely on symptoms to know whether or not you are infected with HIV. Many people who are infected with HIV do not have any symptoms at all for many years.

The following may be warning signs of infection with HIV:

* Gross weight loss
* Gross weight loss
* Gross appetite loss
* Repeated loose motions
* Repeated fever
* Tired without apparent reason
* Night sweats
* Bleeding from any part of the body
* Neck glands/swelling
* Repeated skin rash
* Coloured patch/s on the skin
* White tongue
* Gross forgetfulness
* Loss of interest in life
* Repeated angry moods
* Sudden impulses to act

However, no one should assume they are infected if they have any of these symptoms. Each of these symptoms can be related to other illnesses. Again, the only way to determine whether you are infected is to be tested for HIV infection

4)How long after a possible exposure should I wait to get tested for HIV?

The tests commonly used to detect HIV infection actually look for antibodies produced by your body to fight HIV. Most people will develop detectable antibodies within 3 months after infection, the average being 25 days. In rare cases, it can take up to 6 months. For this reason, the CDC currently recommends testing 6 months after the last possible exposure (unprotected vaginal, anal, or oral sex or sharing needles). It would be extremely rare to take longer than 6 months to develop detectable antibodies. It is important, during the 6 months between exposure and the test, to protect yourself and others from further possible exposures to HIV.

5)What do the test results mean?

POSITIVE RESULTS:

* Your blood has been tested with both the screening test called the ELISA and a continuing test called the WESTERN BLOT.
* You are infected with HIV.
* You must assume you can infect other people.
* You may or may not develop AIDS or HIV related symptoms

NEGATIVE RESULTS

* You are not infected with HIV; or
* You may be infected, BUT your body has not yet produced enough antibodies for detection. Antibody production generally takes up to 3 months after infection, but in some cases up to 6 months or longer before antibodies can be detected. Sometimes a retest is necessary.
* You may be infected, but your body won't produce antibodies, (which is very rare).

A person who engages in high-risk activities and tests negative should realize there can be false negatives - that is, a person could be infected even though the antibody test is negative. A person who tests positive OR who engages in high-risk activities should NOT donate blood, semen, organs or tissue. They should use risk reduction during sexual activity. A confirmed positive test means you have been infected with HIV. It does NOT mean you have AIDS or will develop AIDS. If you test positive, further evaluation is necessary to see if you have immune damage or any condition that indicates AIDS. A person who tests positive is infectious and can pass the virus to others.

Remember that negative results are not a guarantee that you are immune to a future infection of HIV. Safer sex/risk reduction must be practiced now and in the future.

6)How is HIV transmitted?

HIV transmission can occur when blood, semen (including pre-seminal fluid or "pre-cum"), vaginal fluid, or breast milk from an infected person enters the body of an uninfected person.

HIV can enter the body through the anus or rectum, the vagina, the penis, the mouth, other mucous membranes (e.g., eyes or inside of the nose), cuts and sores or through a vein (e.g., injection drug use). Intact, healthy skin is an excellent barrier against HIV and other viruses and bacteria.

Modes Of transmission

These are the most common ways that HIV is transmitted from one person to another:

* by having sexual intercourse (anal, vaginal, or oral sex) with an HIV-infected person
* by sharing needles or injection equipment with an injection drug user who is infected with HIV
* from HIV-infected women to babies before or during birth, or through breast-feeding after birth

Some health-care workers have become infected after being stuck with needles containing HIV-infected blood. Hence all health workers should use barriers like gloves, masks when attending to HIV positive patients.

HIV is not easily transmitted. It is NOT spread through the air, through water, by insects, or during ordinary social contact. It has NEVER been transmitted by casual contact

7)Can I get HIV from performing oral sex?

Yes, it is possible for you to become infected with HIV through performing oral sex. There have been a few cases of HIV transmission from performing oral sex on a person infected with HIV. Evidence suggests that the risk is less than that of unprotected anal or vaginal sex.

Blood, semen, pre-seminal fluid, and vaginal fluid all may contain the virus. Cells in the mucous lining of the mouth may carry HIV into the lymph nodes or the bloodstream. The risk increases

* if you have cuts or sores around or in your mouth or throat;
* if your partner ejaculates in your mouth; or
* If your partner has another sexually transmitted disease (STD).

8)Can I get HIV from anal sex?

Yes, it is possible for either sex partner to become infected with HIV during anal sex. HIV can be found in the blood, semen, pre-seminal fluid, or vaginal fluid of a person infected with the virus. In general, the person receiving the semen is at greater risk of getting HIV because the lining of the rectum is thin and may allow the virus to enter the body during anal sex. However, a person who inserts his penis into an infected partner also is at risk because HIV can enter through the urethra (the opening at the tip of the penis) or through small cuts, abrasions, or open sores on the penis.

Having unprotected (without a condom) anal sex is considered to be a very risky behavior. If people choose to have anal sex, they should use a latex condom. Most of the time, condoms work well. However, condoms are more likely to break during anal sex than during vaginal sex. Thus, even with a condom, anal sex can be risky. A person should use a water-based lubricant in addition to the condom to reduce the chances of the condom breaking.

9)Why is injecting drugs a risk for HIV?

At the start of every intravenous injection, blood is introduced into needles and syringes. HIV can be found in the blood of a person infected with the virus. The reuse of a blood-contaminated needle or syringe by another drug injector carries a high risk of HIV transmission because infected blood can be injected directly into the bloodstream.

In addition, sharing drug equipment can be a risk for spreading HIV.

10)Is there a connection between HIV and other sexually transmitted diseases?

Yes. Having a sexually transmitted disease (STD) can increase a person's risk of becoming infected with HIV, whether the STD causes open sores or breaks in the skin (e.g., syphilis, herpes, chancroid) or does not cause breaks in the skin (e.g., chlamydia, gonorrhea).

If the STD infection causes irritation of the skin, breaks or sores may make it easier for HIV to enter the body during sexual contact. Even when the STD causes no breaks or open sores, the infection can stimulate an immune response in the genital area that can make HIV transmission more likely.

In addition, if an HIV-infected person is also infected with another STD, that person is three to five times more likely than other HIV-infected persons to transmit HIV through sexual contact.

Not having (abstaining from) sexual intercourse is the most effective way to avoid STD's, including HIV. For those who choose to be sexually active, the following HIV prevention activities are highly effective:

* Engaging in sex that does not involve vaginal, anal, or oral sex
* Having intercourse with only one uninfected partner
* Using latex condoms every time you have sex

Hepatitis A

2007-01-12T19:54:00.000+01:00

Viral Hepatitis A.
Hepatitis (HEP-ah-TY-tis) makes your liver swell and stops it from working right. You need a healthy liver. The liver does many things to keep you alive. The liver fights infections and stops bleeding. It removes drugs and other poisons from your blood. The liver also stores energy for when you need it.

1>What are the signs and symptoms of hepatitis A?.
Persons with hepatitis A virus infection may not have any signs or symptoms of the disease. Older persons are more likely to have symptoms than children. If symptoms are present, they usually occur abruptly and may include fever, tiredness, loss of appetite, nausea, abdominal discomfort, dark urine, and jaundice (yellowing of the skin and eyes). Symptoms usually last less than 2 months; a few persons are ill for as long as 6 months. The average incubation period for hepatitis A is 28 days (range: 15–50 days). In less than 2% severe liver failure may lead to death unless an emergency liver transplant is done.

Hepatitis A can make you feel like you have the flu.
You might

* feel tired
* feel sick to your stomach
* have a fever
* not want to eat
* have stomach pain
* have diarrhea

Some people have

* dark yellow urine
* light-colored stools
* yellowish eyes and skin

Some people don't have any symptoms.

If you have symptoms, or think you might have hepatitis A, go to a doctor. The doctor will test your blood.

2>How is hepatitis A diagnosed?.
A blood test (IgM anti-HAV) is needed to diagnose hepatitis A. Talk to your doctor or someone from your local health department if you suspect that you have been exposed to hepatitis A or any type of viral hepatitis.

Most people who have hepatitis A get well on their own after a few weeks.

You may need to rest in bed for several days or weeks, and you won't be able to drink alcohol until you are well. The doctor may give you medicine for your symptoms.

3>How can I protect myself?.
You can get the hepatitis A vaccine.
A vaccine is a drug that you take when you are healthy that keeps you from getting sick. Vaccines teach your body to attack certain viruses, like the hepatitis A virus.

The hepatitis A vaccine is given through a shot. Children can get the vaccine after they turn 2 years old. Children aged 2 to 18 will need three shots. The shots are spread out over a year. Adults get two or three shots over 6 to 12 months.

You need all of the shots to be protected. If you miss a shot, call your doctor or clinic right away to set up a new appointment.

You can protect yourself and others from hepatitis A in these ways, too:

* Always wash your hands after using the toilet and before fixing food or eating.
* Wear gloves if you have to touch other people's stool. Wash your hands afterwards.
* Drink bottled water when you are in another country. (And don't use ice cubes or wash fruits and vegetables in tap water.)

4>Who can get hepatitis A?.
Anyone can get hepatitis A.

But some people are more likely to than others:

* people who live with someone who has hepatitis A
* children who go to day care
* people who work in a day care center
* men who have sex with men
* people who travel to other countries where hepatitis A is common

5>How is hepatitis A virus transmitted?.
Hepatitis A virus is spread from person to person by putting something in the mouth that has been contaminated with the stool of a person with hepatitis A. This type of transmission is called "fecal-oral." For this reason, the virus is more easily spread in areas where there are poor sanitary conditions or where good personal hygiene is not observed.

Most infections result from contact with a household member or sex partner who has hepatitis A. Casual contact, as in the usual office, factory, or school setting, does not spread the virus.

* eating food that has been prepared by someone with hepatitis A
* drinking water that has been contaminated by hepatitis A (in parts of the world with poor hygiene and sanitary conditions)

6>What products are available to prevent hepatitis A virus infection?.
Two products are used to prevent hepatitis A virus infection: immune globulin and hepatitis A vaccine.

* Immune globulin is a preparation of antibodies that can be given before exposure for short-term protection against hepatitis A and for persons who have already been exposed to hepatitis A virus. Immune globulin must be given within 2 weeks after exposure to hepatitis A virus for maximum protection.
* Hepatitis A vaccine has been licensed in the United States for use in persons 2 years of age and older. The vaccine is recommended (before exposure to hepatitis A virus) for persons who are more likely to get hepatitis A virus infection or are more likely to get seriously ill if they do get hepatitis A. The vaccines currently licensed in the United States are HAVRIX® (manufactured by GlaxoSmithKline) and VAQTA® (manufactured by Merck & Co., Inc).

7>How are hepatitis A vaccines made?
There is no live virus in hepatitis A vaccines. The virus is inactivated during production of the vaccines, similar to Salk-type inactivated polio vaccine.

8>Is hepatitis A vaccine safe?
Yes, hepatitis A vaccine has an excellent safety profile. No serious adverse events have been attributed definitively to hepatitis A vaccine. Soreness at the injection site is the most frequently reported side effect.

9>Any adverse event suspected to be associated with hepatitis A vaccination should be reported to the Vaccine Adverse Events Reporting System (VAERS). VAERS forms can be obtained by calling 1-800-822-7967.

10>Is immune globulin safe?.
Yes. No instance of transmission of HIV (the virus that causes AIDS) or other viruses has been observed with the use of immune globulin administered by the intramuscular route. Immune globulin can be administered during pregnancy and breast-feeding.

11>Can other vaccines be given at the same time that hepatitis A vaccine is given?
Yes. Hepatitis B, diphtheria, poliovirus (oral and inactivated), tetanus, oral typhoid, cholera, Japanese encephalitis, rabies, yellow fever vaccine or immune globulin can be given at the same time that hepatitis A vaccine is given, but at a different injection site.

12>How long does immunity last after hepatitis A vaccination?
Although data on long-term protection are limited, estimates based on modeling techniques suggest that protection will last for at least 20 years.

13>When are persons protected after receiving hepatitis A vaccine?.
One month after receiving the first dose of hepatitis A vaccine, 94-100% of adults and children will have protective antibodies. Many persons will have protective antibodies by 2 weeks after the first vaccine dose. However, to receive optimal protection, the first dose of hepatitis A vaccine should be given 4 weeks prior to time of desired protection. Those who need optimal protection earlier than 4 weeks after the first dose of vaccine should also receive immune globulin. The second dose of vaccine in 6-18 months is necessary to assure long term protection. Check with your doctor for when the next dose is due.

14>Can hepatitis A vaccine be given after exposure to hepatitis A virus?
No, hepatitis A vaccine is not licensed for use after exposure to hepatitis A virus. In this situation, immune globulin should be used.

15>Should pre-vaccination testing be done?
Pre-vaccination testing is done only in specific instances to control cost (e.g., persons who were likely to have had hepatitis A in the past). This includes persons who were born in countries with high levels of hepatitis A virus infection, elderly persons, and persons who have clotting factor disorders and may have received factor concentrates in the past.

16>Should post-vaccination testing be done?
No.

17>Can a patient receive the first dose of hepatitis A vaccine from one manufacturer and the second (last) dose from another manufacturer?
Yes. Although studies have not been done to look at this issue, there is no reason to believe that this would be a problem.

18>What should be done if the second dose of hepatitis A vaccine is delayed?
The second dose should be administered as soon as possible. There is no need to repeat the first dose.

19>Can hepatitis A vaccine be given during pregnancy or lactation?
We don't know for sure, but because vaccine is produced from inactivated hepatitis A virus, the theoretical risk to the developing fetus is expected to be low. The risk associated with vaccination, however, should be weighed against the risk for hepatitis A in women who may be at high risk for exposure to hepatitis A virus.

20>Can hepatitis A vaccine be given to immunocompromised persons? (e.g., persons on hemodialysis or persons with AIDS)
Yes.

Hepatitis B

2007-01-12T19:52:00.000+01:00

Q: What is hepatitis B?
A: Hepatitis B (HBV) is a liver disease. HBV infection can cause acute illness that leads to loss of appetite; tiredness; pain in muscles, joints, or stomach; diarrhea or vomiting; and yellow skin or eyes (jaundice). HBV can also cause chronic infection, especially in infants and children, that leads to liver damage (cirrhosis), liver cancer, and death.

Q: What causes hepatitis B?
A: Hepatitis B is a serious disease caused by the hepatitis B virus (HBV) which is present in the blood and body fluids of an infected individual. The virus can be transmitted from mother to baby at birth as well as through unprotected sexual intercourse, and unsterilized needles.

Q: Significance of hepatitis B?
A: Each year in the United States, an estimated 200,000 people have new HBV infections, of whom more than 11,000 people are hospitalized and 20,000 remain chronically infected. Overall, an estimated 1.25 million people in the United States have chronic HBV infection, and 4,000 to 5,000 people die each year from hepatitis B related chronic liver disease or liver cancer (Centers for Disease Control and Prevention (CDC), 1990; Margolis, 1991; West, 1992).

Q: How can I get hepatitis B?
A: Hepatitis B spreads by contact with an infected person's blood, semen, or other body fluid. One out of 20 people in the United States will get hepatitis B some time during their lives. Your risk is higher if you:

* Have sex with someone infected with HBV.
* Have sex with more than one partner.
* Are a man and have sex with a man.
* Share drug needles.
* Getting a tattoo or body piercing with dirty tools that were used on someone else.
* Have a job that involves contact with human blood.
* Getting pricked with a needle that has infected blood on it (health care workers can get hepatitis B this way).
* Are a resident or work in a home for the developmentally disabled.
* Have received blood products (for example: for hemophilia, bleeding, or surgery, etc.)
* Share a toothbrush or razor with an infected person.
* Live in the same house with someone who has lifelong HBV infection.
* Travel to areas where hepatitis B is common.
* If you or your parents were born in Southeast Asia, Africa, the Amazon Basin in South America, the Pacific Islands, and the Middle East.
* An infected woman can give hepatitis B to her baby at birth or through her breast milk.

If you are at risk for HBV infection, ask your health care provider about hepatitis B vaccine.

You can not get hepatitis B by :

* Shaking hands with an infected person.
* Hugging an infected person.
* Sitting next to an infected person.

Q: What are the symptoms?
A: Hepatitis B can make you feel like you have the flu. You might:

* Feel tired.
* Feel sick to your stomach.
* Have a fever.
* Not want to eat.
* Have stomach pain.
* Have diarrhea.

Some people have

* Dark yellow urine.
* Light-colored stools.
* Yellowish eyes and skin.

Q: What are the tests for hepatitis B?
A: To check for hepatitis B, the doctor will test your blood. These tests show if you have hepatitis B and how serious it is. The doctor may also do a liver biopsy. Biopsy (BYE-op-see) is a simple test. The doctor removes a tiny piece of your liver through a needle.The doctor checks the piece of liver for signs of hepatitis B and liver damage.

Q: Is there a cure for hepatitis B?
A: There is no cure for hepatitis B; this is why prevention is so important. Hepatitis B vaccine is the best protection against HBV. Three doses are needed for complete protection.

Q: Carrier of hepatitis B virus?
A: Sometimes, people who are infected with HBV never recover fully from the infection; they carry the virus and can infect others for the rest of their lives. In the United States, about one million people carry HBV.

Q: If you are pregnant, should you worry about hepatitis B?
A: If you have HBV in your blood. you can give hepatitis B to your baby. Babies who get HBV at birth may have the virus for the rest of their lives, can spread the disease. and can get cirrhosis of the liver or liver cancer.
All pregnant women should be tested for HBV early in their pregnancy. If the blood test is positive. the baby should receive vaccine along with another shot. hepatitis B immune globulin (called H-BIG), at birth. The vaccine series should be completed during the first 6 months of life.

Q:How Is hepatitis B treated?
A: Treatment for hepatitis B may involve:

* A drug called interferon (in-ter-FEAR-on). It is given through shots. Most people are treated for 4 months.
* Surgery. Over time, hepatitis B may cause your liver to stop working. If that happens, you will need a new liver. The surgery is called a liver transplant. It involves taking out the old, damaged liver and putting in a new, healthy one from a donor.

Q: Who should receive hepatitis B vaccine?
A:

* All babies, at birth
* All children 11-12 years of age who have not been vaccinated
* All healthcare workers
* All laboratory workers who may have contact with bodily fluids
* Hemodialysis patients
* Hemophiliacs and others who routinely receive blood products
* Household contracts of infected individuals
* Sexual contacts of infected individuals
* Heterosexuals and male homosexuals with multiple partners
* Intravenous drug users
* Persons of any age or gender whose behavior puts them at high risk for HBV infection

Q: Other things you can do to protect yourself from hepatitis B?
A: You can also protect yourself and others from hepatitis B if you:

* Use a condom when you have sex.
* Don't share drug needles with anyone.
* Wear gloves if you have to touch anyone's blood.
* Don't use an infected person's toothbrush, razor, or anything else that could have blood on it.
* Also, if you get a tattoo or body piercing, make sure it is done with clean tools.

Polio :-

2007-01-12T19:47:00.000+01:00

1>What is polio?

Polio (medically referred to as poliomyelitis) is a highly infectious disease caused by a virus. The virus enters the body through the mouth and multiplies in the intestine. Initial symptoms are fever, fatigue, headache, vomiting, stiffness in the neck, and pain in the limbs. It can cause total paralysis in a matter of hours.

2>Does polio cause permanent disability?

One in 200 infections leads to permanent paralysis (usually in the legs). Among those paralyzed, 5%–10% die when their breathing muscles become immobilized.

3>Who can get polio?

Polio mainly affects children under five years of age.

4>Is there a cure for polio?

Unfortunately, there is no cure for polio. It can only be prevented.

5>How can I protect my child from getting polio?

The only sure way is to make sure that your child receives the polio vaccine. Please consult your family doctor for more details.

I thought polio had been eradicated.

While the number of cases of polio has decreased significantly since 1988, the disease remains active in certain parts of the world including parts of India, Nigeria, Egypt, Pakistan, Afghanistan, Somalia and Niger.

6>How do the needs of children with polio differ from those of able-bodied children?

Because of their physical handicaps, children with polio may need aids for mobility e.g. wheelchairs. Fortunately, the poliovirus does not affect the brain and as such these children can attend regular schools and do not require special classes. Many go on to become high achievers such as President Franklin D. Roosevelt, who was paralyzed in both legs by polio at the age of 39.

7>Why aren't the governments of countries where polio is endemic doing something about it?

Working with local governments, the WHO's Global Polio Eradication Initiative has undertaken a massive vaccination campaign. For example, in 2002, more than 500 million children in 93 countries were vaccinated against polio. Today, more than 5 million people, who would otherwise have been paralyzed with polio, are walking because of this initiative. Unfortunately, such initiatives are very costly with the result that funds are scarce for rehabilitation of the unfortunate ones who do contract polio.

8>Why do children with polio need long term follow up?

It is important that these children follow standard healthy lifestyles including consuming a healthy and a well-balanced diet, exercising in moderation, and visiting a doctor regularly so that they can cope better should they develop post-polio syndrome.

9>What is post-polio syndrome?

Post-Polio Syndrome (PPS) is a condition that can strike polio survivors anywhere from 10 to 40 years after their recovery from polio. Symptoms include fatigue, slowly progressive muscle weakness, muscle and joint pain, and muscular atrophy. Doctors estimate the incidence of PPS at about 25 percent of the survivor population.

Cancer :- Mesothelioma

2007-01-12T19:40:00.000+01:00

Mesothelioma is a rare form of cancer in which malignant (cancerous) cells are found in the mesothelium, a protective sac that covers most of the body’s internal organs. Most people who develop mesothelioma have worked on jobs where they inhaled asbestos particles(like in ship breaking industry)

1. What is the mesothelium?

The mesothelium is a membrane that covers and protects most of the internal organs of the body. It is composed of two layers of cells: One layer immediately surrounds the organ; the other forms a sac around it. The mesothelium produces a lubricating fluid that is released between these layers, allowing moving organs (such as the beating heart and the expanding and contracting lungs) to glide easily against adjacent structures.

The mesothelium has different names, depending on its location in the body. The peritoneum is the mesothelial tissue that covers most of the organs in the abdominal cavity. The pleura is the membrane that surrounds the lungs and lines the wall of the chest cavity. The pericardium covers and protects the heart. The mesothelial tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.

2. What is mesothelioma?

Mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs. Cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum.

3. How common is mesothelioma?

Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. About 2,000 new cases of mesothelioma are diagnosed in the United States each year. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age.

4. What are the risk factors for mesothelioma?

Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos.

Asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. Asbestos has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.

Smoking does not appear to increase the risk of mesothelioma. However, the combination of smoking and asbestos exposure significantly increases a person’s risk of developing cancer of the air passageways in the lung.

5. Who is at increased risk for developing mesothelioma?

Asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure.

The risk of asbestos-related disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma. On the other hand, not all workers who are heavily exposed develop asbestos-related diseases.

There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma, and possibly other asbestos-related diseases. This risk may be the result of exposure to asbestos dust brought home on the clothing and hair of asbestos workers. To reduce the chance of exposing family members to asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.

6. What are the symptoms of mesothelioma?

Symptoms of mesothelioma may not appear until 30 to 50 years after exposure to asbestos. Shortness of breath and pain in the chest due to an accumulation of fluid in the pleura are often symptoms of pleural mesothelioma. Symptoms of peritoneal mesothelioma include weight loss and abdominal pain and swelling due to a buildup of fluid in the abdomen. Other symptoms of peritoneal mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.

These symptoms may be caused by mesothelioma or by other, less serious conditions. It is important to see a doctor about any of these symptoms. Only a doctor can make a diagnosis.

7. How is mesothelioma diagnosed?

Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient’s medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful. A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed.

A biopsy is needed to confirm a diagnosis of mesothelioma. In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.

If the diagnosis is mesothelioma, the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment.

Mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.

8. How is mesothelioma treated?

Treatment for mesothelioma depends on the location of the cancer, the stage of the disease, and the patient’s age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy. Sometimes, these treatments are combined.

* Surgery is a common treatment for mesothelioma. The doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural mesothelioma), a lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.

* Radiation therapy, also called radiotherapy, involves the use of high-energy rays to kill cancer cells and shrink tumors. Radiation therapy affects the cancer cells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the cancer cells are found (internal radiation therapy).

* Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat mesothelioma are given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).

To relieve symptoms and control pain, the doctor may use a needle or a thin tube to drain fluid that has built up in the chest or abdomen. The procedure for removing fluid from the chest is called thoracentesis. Removal of fluid from the abdomen is called paracentesis. Drugs may be given through a tube in the chest to prevent more fluid from accumulating. Radiation therapy and surgery may also be helpful in relieving symptoms.

9. Are new treatments for mesothelioma being studied?

Yes. Because mesothelioma is very hard to control, the National Cancer Institute (NCI) is sponsoring clinical trials (research studies with people) that are designed to find new treatments and better ways to use current treatments. Before any new treatment can be recommended for general use, doctors conduct clinical trials to find out whether the treatment is safe for patients and effective against the disease. Participation in clinical trials is an important treatment option for many patients with mesothelioma.

Dieting FAQs and Myths

2007-01-11T20:26:00.000+01:00

Why Should You Avoid Crash or Fad Diets?

There is nothing magical about fad diets. Their secret involves significant and drastic reduction in calories. People following these diets are basically starving themselves by eating watery soups and vegetables. They can't help but lose a lot of water weight and not fat. Crash diets severely limit food choices or are unbalanced in some way. For example, only sprouts or boiled vegetables are suggested eliminating all other food choices. Since, fad diets do nothing to change long term eating habits, most fad dieters' gain back more weight than they lost as soon as they go back to their old ways of eating.

What is Invisible Fat?

This is the hidden fat present in all foods in varying amounts. For example, nuts and oilseeds like peanuts, sesame seeds etc. contain plenty of invisible fat as compared to vegetables which contain small amounts of it whereas cereals and pulses contain moderate amounts of invisible fat. To put it simply, you get 26 grams of invisible fat from 100 grams of peanuts in comparison 100 grams of spinach contains only 0.7 grams of invisible fat. If you are on a weight loss program, it is important to remember that these can add on to the total fat (and calories) consumed in a day.

Sugar, Jaggery or Honey - which one is better?

Sugar, jaggery or honey provide you approximately the same amount of calories (1 teaspoon = 20 calories) and no appreciable amounts of other nutrients. It is better to use jaggery for recipes (but restrict the quantities) as compared to sugar and honey as it is a good source of iron. You don't have to go on a sugar eliminating diet to lose weight but it is a good idea to cut on sugar and to satisfy your sweet cravings by eating small portions of a low calorie dessert or a piece of fruit instead.

What are Empty Calories?

Calories obtained from foods that are completely void of nutrients are called "empty calories". Aerated drinks, refined sugar and alcohol are foods that provide you only calories (empty calories) which could lead to weight gain as all excess calories are converted into fat and stored in your body. So, it is best to avoid these foods to effectively lose weight.

Are Fruits Healthier than their Juices?

Yes, fruits are healthier than their juices because the process of extracting juice removes all the fibre present in the fruit. Fibre is essential as it aids digestion, relieves constipation and lowers blood cholesterol levels. It adds bulk to your diet and keeps you satiated for a longer period of time. If a glass of fruit juice is what you want to have, do not strain fruit juice so as to retain its fibre. Also resist the temptation to sweeten the juice with sugar to avoid loading it with empty calories, like in the recipe of Fruity Refresher

Rice or Wheat - which one is healthier?

Whole wheat is richer in fibre than the polished rice we are used to consuming. Rice has approximately the same calories as whole wheat and hence is not more fattening. But the kind of rice you choose is of utmost importance. Brown rice (unpolished rice) abounds in fibre which aids in digestion while helping to lower your blood cholesterol levels whereas white rice (polished rice) loses this important nutrient (i.e. fibre) during processing. If you don't like the taste of brown rice, it is wiser to opt for whole wheat or eat small portions of white rice with large servings of vegetables (as they are rich in fibre). Alternatively a one-meal combination of rice cooked with plenty of vegetables, like in the recipe of Vegetable Biryani is also a healthy option.

Do You Need to Eliminate Dairy Products, If You Wish to Lose Weight?

You don't need to eliminate dairy products when you are on a reducing diet, as they are the biggest source of calcium that is essential for healthy bones and teeth. They also provide substantial amounts of protein and vitamins A and B. But you should replace high fat dairy products (like full fat milk and milk powder, curds, cottage cheese etc.) with their low fat alternatives (skim or low fat milk products) when you aim to lose weight. Low fat dairy products are equally good sources of the above said nutrients, with fewer calories and traces of fat. However, you need to skip dairy foods like cheese, cream and butter, as these are very high in fat.

Are Soups and Salads Always Low in Calories?

It is true that soups and salads are nourishing as they make use of a wide variety of raw vegetables, fresh fruits and sprouts but we often make them unhealthy by using salad dressings like mayonnaise and by loading soups with butter, cream, cheese etc. These ingredients are very high in calories, fat and cholesterol and do no good to your body but rather increase your weight. Instead you should make use of flavorful herbs and spices to prepare delectable soups and salads which are healthy, tasty and low in calories.

Besides the dietary guidelines I've discussed above, high-self esteem is equally important to maintain a healthy, balanced lifestyle - and it's a must if successful weight loss is one of your goals. What's more important is that you feel good about who you are and how you look rather than setting unrealistic weight loss targets. Learn to love your body and put yourself in a more positive light. So stop starving and do not junk your body by eating fast foods. Instead, let's get introduced to our vast repertoire of ingredients, herbs and spices and reacquaint ourselves with fresh vegetables and fruits and cook them correctly using 1 teaspoon of oil.

And I bet you'll end up feeling really good and lose weight too…

FAQ :- Diabetes

2007-01-10T23:38:00.001+01:00

What is 'diabetes'?

'Diabetes' is the abbreviated term for a condition known as 'diabetes mellitus'. There are two main forms of diabetes in the general population, type 1 and type 2. A third type, known as 'gestational diabetes' is associated with pregnancy. All forms of diabetes involve a reduced ability of the body to handle blood glucose (the type of sugar transported in the blood).

In normal health, blood glucose is maintained at a fairly constant level, although it does fluctuate slightly. Blood glucose level is controlled largely by the action of insulin, a hormone produced in the pancreas. Insulin stimulates the uptake of glucose, amino acids and fat (in the form of triglycerides) from the blood into the tissues for use. Insulin also promotes the storage of blood glucose in the liver and muscles. Thus insulin prevents the glucose level becoming too high in the blood. If insulin production is too low, or the insulin does not have its usual effect, blood glucose can climb
to dangerous levels (a condition known as 'hyperglycaemia'). When blood glucose levels are high over long periods of time, damage to cells within the body can result. For example, nerve and vascular damage are common.

Type 1 diabetes, previously known as 'juvenile-onset' or 'insulin-dependent diabetes mellitus' (IDDM), involves destruction of the cells of the pancreas that produce insulin, so people with type 1 diabetes have a deficiency of insulin. As a result, injections of insulin are required.

Type 2 diabetes, previously known as 'adult-onset' or 'non-insulin-dependent diabetes mellitus' (NIDDM), does not usually involve a deficiency of insulin production (at least not in the initial stages), rather, the body becomes resistant' to the effects of insulin. While type 2 diabetes is at this early stage, lifestyle changes (discussed in detail below) such as diet and exercise diet may be enough to control blood sugar levels with no (or minimal) need for medication. However, type 2 diabetes may progress to the stage where regular medication is also needed. In some cases, as diabetes progresses, a combination of treatments may be required. This could mean an altered diet, lifestyle changes, regular medication and insulin injections may all be necessary.

Gestational diabetes is usually only a temporary condition, affecting about 3% of pregnant women. Individuals who experience gestational diabetes have greater risk of developing type 2 diabetes in the future.

Because the vast majority (more than 90%) of people with diabetes have type 2, and its incidence is growing in epidemic proportions, this FAQ will address mainly type 2 diabetes. For more information on type 1 and gestational diabetes, see 'Suggested Additional Reading' at the end of this FAQ.

How does having type 2 diabetes affect someone's health?

Diabetes, unless treated appropriately, greatly increases the risk of a range of diseases, including heart disease, blindness, gangrene (leading to the need for limb amputations) and kidney disease. It is estimated that the risk of having a heart attack among people with type 2 diabetes is equal to that of someone without diabetes who has already experienced a heart attack.

But diabetes greatly increases these risks only if it is not treated
effectively. With proper management, including appropriate alterations to diet and lifestyle as described below, the vast majority of people with diabetes can lead full and satisfying lives.

How widespread is type 2 diabetes?

Just as the developed world is undergoing an epidemic of obesity, so also the incidence of type 2 diabetes is rapidly increasing. This is not a coincidence--obesity is the major risk factor for type 2 diabetes. From the early 1980s to 2000 there was a doubling of the rate of obesity in Australia. Paralleling this, the diabetes rate has at least doubled, and may even have trebled in the past 20 years. The relationship between obesity and diabetes is at least as strong as that between smoking and lung cancer--that
is, if you carry a substantial excess of body fat, your chances of
developing type 2 diabetes are increased by more than ten times compared to someone in the healthy weight range. According to a press release issued by International Diabetes Institute in May 2000, it is estimated that about 7-8% of Australian adults (over the age of 25) now have type 2 diabetes, and 16% have its precursor, impaired glucose tolerance.

But many people who have only recently developed diabetes are not yet aware of their condition. In fact it is estimated that in Australia 50% of sufferers are undiagnosed. This is a potentially dangerous situation, because of the complications of diabetes previously described. In 2000, the Federal Minister for Health called diabetes a 'time bomb' for public health in Australia, as the seventh highest leading cause of death.

Who is at greatest risk of developing type 2 diabetes?

Until recently, type 2 diabetes was considered as the 'adult onset'
form--that is, it was rarely seen other than in middle-aged and older people. However, it is now affecting younger people as well. For example, one recent study found that nearly 5% of children in the United States have early signs of type 2 diabetes. But it is still true that the risk increases with age. Some population groups are also at special risk including:

Aboriginal and Torres Strait Islanders, Pacific Islanders, people from the Indian Subcontinent, and people of Chinese origin (in each case the risk increases substantially from age 35 on);

People of any race or background over 45 years who have high body fat levels and/or high blood pressure ('hypertension');

Women with polycystic ovary disease;

Women with previous gestational diabetes;

People 55 years and over; and People 45 years and over with a family history of type 2 diabetes.

If I don't have diabetes, what can I do to reduce my chances of developing it?

There is a strong relationship between a group of metabolic conditions known as the 'metabolic syndrome' or 'syndrome X' and risk of diabetes. The components of metabolic syndrome include obesity, high blood levels of triglycerides and 'LDL' (the 'bad' cholesterol), low blood 'HDL' (the 'good' cholesterol) and high blood pressure. These are also among the major risk factors for heart disease, so dietary and lifestyle advice for avoiding diabetes is pretty much the same as for reducing the risk of heart disease.
In summary, the advice includes:

follow the dietary guidelines (see Appendix 1 for those guidelines that are most relevant to avoiding diabetes);

reduce body weight (if overweight or obese--see Appendix 2 for definitions);
and increase physical activity (if previously sedentary or only slightly active).

As recommended in the first dietary guideline shown in Appendix 1, eating plenty of wholegrain cereal foods (e.g. wholegrain bread, rice, pasta), legumes, vegetables and fruits is one of the most beneficial aspects of diet for reducing the risk of diabetes (and many other diseases). Reducing intake of total fat and, in particular, saturated fat (second guideline in Appendix
1) is also very important.

Because reducing body weight is associated with improvement in all components of the metabolic syndrome, losing some weight (if you have excess body fat) is also very important. This is illustrated by studies conducted in the US and Finland, which found a significant reduction in progression from 'impaired glucose intolerance' (the condition that predisposes to diabetes) to actual diabetes in those people who lost weight.

The effect of obesity on diabetes risk is also graphically illustrated by recent results from the US, where nearly 20% of children are obese, and one quarter of these children have impaired glucose tolerance.

But physical activity is probably just as important as diet and weight control (and impacts beneficially on the latter). For general health, (including reducing the risk of developing type 2 diabetes) Active Australia recommends a minimum of 30 minutes of planned moderately-vigorous activity each day, with some vigorous activity as well. This planned activity is in addition to any incidental activity. Companion FAQs in this series provide more information on appropriate types and levels of activity for general health, for weight control, and for physical fitness.

Because type 2 diabetes (and obesity) are increasing in young people, encouraging children to be more active is especially important in reducing the risk of later development of diabetes. Turning off the television and the computer, and sending the children outside to play (under safe conditions, of course) may be one of the most health-promoting influences parents can have on their children. Allowing them to walk short distances--or better still, walking with them--rather than driving them also promotes metabolic fitness and weight control.

If I have diabetes, how should I adjust my diet and lifestyle to help keep it under control?

First, always seek (and take) advice from your doctor and/or dietitian. Because no two people have identical metabolism, food preferences, cultures or nutritional requirements, personalised professional advice is essential.
So the advice provided in this answer applies only generally--if you have diabetes, alterations to your diet and lifestyle need to be tailored by your health professional to your individual needs.

The overall goal in treating diabetes is to maintain health and quality of life. The main dietary and lifestyle elements of this strategy will be:

(i) keep blood glucose levels in the range 4-8 mmol/L, and as stable as possible--continually high blood glucose levels increase the risk of complications including heart disease, blindness, kidney disease, and limb amputations;

(ii) lose some body weight (if overweight or obese; see Appendix 2 for definitions);

(iii) optimise blood lipid levels (i.e. blood cholesterol, triglycerides);

(iv) maintain (or regain) normal blood pressure;

(v) quit smoking (if you are a smoker); and

(vi) take part in plenty of moderately-vigorous physical activity.

The remainder of this FAQ is devoted to examining how these components may be put into effect.

(i) Maintain stable blood glucose levels

Contrary to popular opinion, people with diabetes should not severely restrict their intake of all carbohydrate foods. A certain amount of carbohydrate is necessary for the normal functioning of organs that do not have a ready alternative source of energy (e.g. the brain). But the carbohydrate foods eaten should be high in fibre: suitable foods are wholemeal and multigrain breads, brown rice, pasta, vegetables (including beans, peas and other legumes), fruits and low- or reduced-fat milk products.

For the most part, the carbohydrate foods should also be relatively low in 'glycaemic' (also spelled 'glycemic') index (GI). The GI of a food is a measure of how quickly it is digested and the carbohydrate is absorbed into the bloodstream. In other words, how quickly and to what extent blood sugar levels will rise. [For more detailed information on GI, see the companion FAQ in this
series, and also 'Suggested Additional Reading' below]. In brief, foods such as beans and other legumes, oats (e.g. porridge), pasta, wholegrain foods and dairy products have relatively low GI, while potatoes, white bread and rice are among those carbohydrate foods that have relatively high GI. Recent research has shown that low GI diets can improve blood glucose control.

But this does not mean that some relatively high GI foods--e.g. wholemeal bread, rice and potatoes--are unsuitable; as mentioned in the previous paragraph, there are other reasons why these foods are valuable components of the diet for people with diabetes. To assist people in making better food choices, GI is now included on some food labels in Australia.

To maintain stable blood glucose levels it may also be better for some people to eat small meals or snacks frequently (i.e. five or six times per day), rather than three large meals. This may help with improving blood lipid levels too. Check with your doctor and/or dietitian if it might be worthwhile trying this eating pattern.

While sugar itself does not contain any nutrients other than carbohydrate, there is no need to totally avoid it. As research into the glycaemic continued it became apparent that the old idea that sugar is especially inappropriate for people with diabetes is no longer current, as it is now known that sugar (sucrose) doesn't raise blood glucose levels as much as glucose and some starchy foods.

However, blood glucose control is not the only dietary consideration. People with diabetes need to ensure that their diet promotes appropriate body weight (e.g. weight loss if overweight), is low in overall GI (as mentioned above), low in saturated fat, and rich in dietary fibre and essential nutrients. Therefore, small to moderate amounts of sugar found in foods such as flavoured milk (preferably low- or reduced-fat), high-fibre breakfast cereals, and stewed or canned fruit is unlikely to compromise dietary quality. It is best to avoid foods that have high concentrations of carbohydrate (sugar or starch) with no or few other nutrients (e.g. foods such as soft drinks, confectionery, highly-sugared breakfast cereals, sweet biscuits and cakes), especially between meals.

If your doctor and/or dietitian agree that you should try eating five or six light meals per day, you will have to be especially careful about regularly cleaning your teeth to minimise the risk of tooth decay. Also, artificial sweeteners can be used to replace some sugar, e.g. for sweetening hot beverages and soft drinks.

Finally, alcohol--although not a necessary part of anyone's diet--can safely be taken in moderation. A maximum of one or two drinks per day is acceptable(but check with your doctor to see if any prescribed drugs you are taking are incompatible with alcohol). Also, drinking alcohol on an empty stomach may lead to low blood glucose levels ('hypoglycaemia') in people with diabetes who require insulin injections. A carbohydrate-containing food should be eaten just before (or with) the alcoholic drink to minimise the risk of hypoglycaemia.

(ii) Lose some body weight (if overweight or obese)

Along with increasing physical activity (and related to it), losing weight is one of the most beneficial changes people can make if they are overweight and have diabetes. Advice on diet and lifestyle changes for weight reduction is provided in companion FAQs in this series. In brief, a small reduction in total food intake and an increase in moderately-vigorous physical activity are recommended to safely reduce body weight, while also maintaining muscle mass. Although getting your weight down to the 'healthy weight range' (see Appendix 2) would be ideal, you will also derive significant health improvements with a weight loss of just 5-10% of your initial weight.

If you are above the healthy weight range it is also important to take into account where on your body you are carrying the extra fat. Fat in the abdominal area (e.g. the 'beer gut' that many Australian men so fondly cultivate) is associated with much greater risk of diabetes than fat on the hips and thighs (which is more common in women). Men should have a waist circumference (at the level of the navel, immediately after breathing out) of no more than about 100 cm. For women, the recommended maximum waist circumference is about 90 cm.

(iii) Optimise blood lipid levels (i.e. blood cholesterol, triglycerides)

The aim should be to reduce to (or maintain at) low levels both your blood cholesterol (especially the 'bad' cholesterol component, LDL) and blood triglycerides. Of course your doctor is the best person to advise you on the safety and effectiveness of the available medical treatments for this, taking into account all your circumstances (including current blood lipid levels, body weight, blood pressure, need for medication, and so on), but to assist in achieving long term dietary change it is also desirable to see a qualified dietitian.

Recent recommendations are that people with diabetes need to be vigilant about keeping blood LDL and triglycerides at low levels. In addition to any medication you may be prescribed, some simple changes to diet and plenty of moderately-vigorous physical activity will also help.

In general terms, if you are overweight, losing some excess body fat may help achieve improved levels of blood cholesterol and triglycerides. In addition, reducing intake of 'saturated' fats (such as those found in butter, full-fat dairy products, most fast foods, fatty meats--including sausages and deli meats--and in most biscuits, cakes and pastries) will promote a reduction in blood cholesterol. As mentioned above, increased consumption of whole grains, fruits and vegetables is recommended to at least partially replace these fatty foods.

But there is no need to severely restrict fat intake, either. There is good evidence that polyunsaturated fats (including the 'omega-3' fats) and monounsaturated fats, can safely and effectively be used to replace much of the saturated fat. Good sources of polyunsaturated and monounsaturated fats include fish, avocado, nuts, seeds (pumpkin, sunflower), canola oil, olive oil, sunflower oil, soybean oil, peanut oil, and margarine spreads. Eating more of these foods in place of those high in saturated fats will help achieve reduction of LDL and triglyceride levels, and reduce the tendency of the blood to clot (thereby reducing the severity of a heart attack if one does occur).

Increasing physical activity will also help improve blood lipid levels, as described under sub-section (vi) below.

(iv) Maintain (or regain) normal blood pressure

High blood pressure is an important risk factor for heart disease and the major risk factor for stroke. Heart disease and stroke are two of the most significant complications of diabetes. Weight reduction (if overweight) will assist in reducing blood pressure. Restricting salt intake is also important because high salt intake is related to high blood pressure.

(v) Quit smoking (if you are a smoker)

Smoking is associated with an increased risk of heart disease (in addition to other non-diabetes-related conditions such as lung cancer, bronchitis, emphysema, osteoporosis and impotence. Some people are reluctant to give up smoking for fear of putting on weight. By increasing physical activity and being careful with their diet, smokers should be able to quit smoking without experiencing a weight gain. But even if there is a slight build up of body fat, this will be outweighed by the health benefits of quitting.
Giving up (or better still, never having taken up) smoking is vital for
people with diabetes if they are serious about managing their condition.

(vi) Take part in plenty of moderately-vigorous physical activity

There is overwhelming evidence that increased physical activity will assist in several aspects of the management of diabetes (and also with promoting good health in general). Taking part in regular, moderately-vigorous activity (preferably also with some vigorous activity) increases HDL, the 'good' fraction of blood cholesterol. It also helps with weight control, reduces blood pressure and assists in keeping blood glucose under control.
[For information on the recommended types and intensities of activity see the companion FAQs in this series on Activity for Weight Control and Activity for General Health and Fitness].

In summary, advice for prevention and treatment of diabetes is generally similar to that for general health and fitness--follow the dietary guidelines; maintain (or regain) the healthy weight range if you can, but at least lose some weight if you are above the healthy weight range; quit smoking (if you are a smoker); and take part in plenty of moderately-vigorous (and some vigorous) physical activity.

In addition to the advice for prevention of diabetes, treatment of diabetes involves (if your doctor and/or dietitian approve) eating five or six small meals (or snacks) rather than three large meals; emphasising foods that provide fibre and/or are low in GI; and increasing the intake of foods rich in unsaturated fats at the expense of saturated fat.

FAQ :- Breast Cancer

2007-01-10T23:29:00.000+01:00

What is breast cancer?
Breast cancer is the result of cells in the breast becoming malignant and developing into a tumor. Although the disease occurs mostly in women, men can get breast cancer, but the occurrence is rare.

What causes breast cancer?
We do not know yet what causes breast cancer. Researchers are working hard to discover why and how certain changes in DNA can cause normal breast cells to become cancerous, and to unlock the secret to understanding the genetic basis of breast cancer.

Can breast cancer be prevented?
There is no certain way. However, women can learn the risk factors (see below) and promote early detection with regular breast self-exams, clinical check-ups and mammograms.

What are the risk factors for breast cancer?
>The highest risk factors are being female and aging
>Menstrual history—if you began menstruating before age 12, or completed menopause after age 55
>Family history—if you have a mother, sister or daughter who has had the disease, or a close relative, such as a cousin or an aunt with a history of breast cancer
>Oral contraceptives—slight increased risk if you are currently using the pill, or have used it in the last 10 years
>Children—if you have never had children or had your first child after age 30
>Alcohol—if you consume one or more alcoholic drinks a day >Being overweight—especially after menopause
>Chest radiation therapy—if you had this as a child or young adult
>Genetic mutations—if you carry the BRCA1 or BRCA2 mutations

What are the symptoms of breast cancer?
>A new lump or mass
>A hard mass that has irregular edges and is painless is more likely to be cancerous. (Cancers can sometimes be tender, soft and rounded, although it is rare.)
>A discharge, other than breast milk
>Redness or pain in the nipple, or on the breast skin
>Retraction of the nipple (turning inward)
>Swelling of the breast that is generalized with no distinct lump

What are the key statistics about breast cancer?
>In 2006, the American Cancer Society estimates that 212,920 new cases of invasive breast cancer (Stages I-IV) will be diagnosed among women in the United States, with 40,970 deaths. There will be approximately 61,980 new cases of DCIS—ductal carcinoma in situ (Stage 0), the non-invasive, earliest form of breast cancer.
>Breast cancer will account for about 15 percent of all cancer-related deaths in women in the nation.
>Increasingly successful therapies and the effect of screening, combined with improved treatment efficacy, have decreased mortality rates and improved survival.
>In men, the ACS estimates 1,720 new cases with 460 deaths.
>Breast Cancer is the second leading cause of cancer death in women, after lung cancer.
>Approximately 5% to 10% of breast cancers can be attributed to genetic predisposition; 20% to 30% of women with breast cancer have a family member with the disease. >Breast cancer is the most common cause of cancer in women (excluding skin cancer). Worldwide, more than a million cases of breast cancer will be detected each year, according to the International Agency for Research on Cancer in Lyon, France.
>In her lifetime, 1 out of 8 women will develop breast cancer.
>Two out of ten breast cancer cases occur in women under the age of 40.
>Overall breast cancer incidence rates are lower in African-American women than in white women. However, African American women are more likely to die from breast cancer. >Asian, Hispanic and American Indian women have a significantly lower risk of breast cancer incidence and mortality.
What are the current trends in breast cancer mortality and survival?
>>Read the February 2006 American Cancer Society report on the historic drop in cancer deaths overall.
>The 5-year survival rate has increased by 12% over the past 30 years, and by 4.6% over the last decade alone.
>In women whose breast cancer is diagnosed at an early stage and is localized, 98% survive more than 5 years.
>>For all stages of breast cancer, the 5-year survival rate is 88%.
>The breast cancer mortality rate dropped 24 percent from 1990--2000: from 49.7 women per 100,000 women ages 40--75 in 1990, to 38 per 100,000 in the same age group in 2000.
>Currently, there are 2 million women, at minimum, living in the U.S. who have survived breast cancer
What is the incidence of breast cancer in younger women?
The number of younger women getting breast cancer has been stable in the last 10 years, and the mortality rate in young women has declined, probably due to early detection and improved treatments. While only 4 to 5% of women under 40 will develop breast cancer, 1 in every 227 women between the ages of 30 and 40 will be diagnosed.

At what age should I begin to examine my breasts?
Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self-exam is an option for women, starting in their 20's. Women should be told about the benefits and limitations of BSE. It is acceptable for women to choose not to do BSE or to doit occasionally. For more information on screening and BSE >>click here.
How often should I have my breasts examined by a health provider?
A clinical breast exam should be part of a periodic health exam, about every three years for women in their 20's and 30's, and every year for women 40 and older.
At what age should I have an annual mammogram?
Yearly mammograms are recommended starting at age 40, and continuing for a long as a woman is in good health.
Do young women have a different type of breast cancer than older women?
No. However, according to the Young Survival Coalition, because young women typically have dense breast tissue, a mammogram is not always the best diagnostic tool for them. For this reason, and because dense breasts also make it more difficult to feel a lump, it is crucial that women ages 20 and older become familiar with their breasts and make sure they get regular clinical exams.

What is Inflammatory Breast Cancer?
Inflammatory breast cancer is a type of breast cancer in which the breast looks red and swollen, and feels warm. The skin of the breast may also show the pitted appearance called peau d'orange (like the skin of an orange). The redness and warmth occur because the cancer cells block the lymph vessels in the skin. Symptoms can also include a lump or thickening in or near the breast or in the underarm area, a change in the size or shape of the breast, nipple discharge or tenderness, or the nipple pulled back (inversion) into the breast.

Why is it recommended that women under age 40 not get regular mammograms?
The breasts of young women contain many glands and ligaments, which appear dense on a mammogram. This radiologic density makes it more difficult to spot tumors, or to tell cancerous conditions. With age, the glandular and fibrous tissues of the breast gradually give way to fatty tissue. Because fatty tissue has less radiologic density, mammograms can more easily "see" into the breast tissue and detect abnormal changes.
Although mammograms are not generally recommended as part of regular screening for women under age 40, women at increased risk (family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (such as breast ultrasound and MRI), or having more frequent exams. In 1985, only about 20% of women were estimated to have had mammograms in the prior two years. By 2000, this figure had increased to 70%.
Are mammograms safe?
Yes. Over ten years ago, radiation dosage was significantly higher than it is now, so women had grounds for concern about the safety of mammograms. Today’s specialized mammography units produce better, more accurate images with a considerably lower x-ray dose than the general purpose x-rays previously used. Since 1994, all U.S. mammography facilities must be certified by the FDA to ensure uniform quality of procedures and a safe level of radiation dosage.

What is Lymphedema?
Women who have been treated for breast cancer may be at risk for lymphedema, or arm swelling. The swelling can range from mild to severe, and it can develop soon after surgery or radiation treatment, or many months or even years later. Additional information about lymphedema can be found on the American Cancer Society web site (www.cancer.org) --go to the breast cancer resource center and search for Lymphedema.