Chapter – 7 

Children Health

Childhood vaccines are one of the great triumphs of modern medicine.  Dr. Ezekiel Emanuel

Infant and childhood death has fallen worldwide thanks to better public health measures – clean water, sewage, immunization, better nutrition and better medical care.  However, in most developing countries, lots of children are still dying from preventable and treatable diseases.  In developed countries childhood obesity is becoming a big problem.

Some of the steps you can take to keep your children healthy are:

• Healthy eating habits

Like adults children should eat a variety of nutritious foods.  Their diet should include plenty of vegetables and fruits, whole-grain cereals, low-fat dairy products, eggs, fish, poultry and lean meats.  Sugar and salt added snacks and drinks should be avoided.  All the newborns and infants should be breast-fed.

• Physical activity

Children should get 60 – 90 minutes physical activity most of the days of the week. The activity can include house hold chores, playing sports, running, and bicycling or otherplayground activities.

• Limiting screen time

Watching too much television, or lap-top or cell-phone, contributes to obesity.  Pediatricians recommend no more than 2 hours of screen time for children over age 2 and none for children under 2.

• Getting enough sleep

All children should get a good night sleep otherwise they end up being drowsy and irritable the following day.  Here are some ways you can cope with bed-time resistance.

• Set a regular time for sleep and stick to it.
• Avoid active play right before bed time.
• Establish a relaxing bed time routine-like reading a story.
• Avoid drinks with caffeine.
• Do not keep the room too warm or too cold.
• Don’t put a T.V,computer, or other electronic media in your child’s bedroom.

Preventing Common Childhood Infections

A child’s immune system constantly encounters, fights, and develops resistance to microorganism that causes disease.  By adulthood the immune system has built up a defense against a wide range of infections.  Most childhood infections are caused by viruses and bacteria that infect the airways or the digestive system.

• Childhood Immunization

Many once-common childhood infections can now be prevented by routine vaccinations.  A vaccination is usually a shot or oral drop, that helps prevent the development of specific disease.  Some vaccinations require a single shot; others require a series of shots or oral drops over time.  Your child’s doctor can suggest the exact timing that is best for each vaccination.  New vaccines are always being developed.  Your child’s doctor will have the latest recommendations.  Follow his/’her advice and get your child vaccinated.  Vaccines available at present are:

For Children

• Diphtheria
• Hepatitis B
• Hemophilus influenza type-b (Hib)
• Human papillomavirus (for cancer)
• H₁N₁flu
• Human papilloma virus for cervical cancer
• Influenza
• Measles
• Meningococcal bacteria (for meningitis)
• Mumps
• Pertussis (Whooping cough)
• Pneumococcal bacteria (for pneumonia)
• Rabies ( mad dog bite)
• Rotavirus (for diarrhea)
• Rubella (German measles)
• Tetanus
• Tuberculosis
• Typhoid fever
• Varicella (Chicken pox)

For Adults-

• All above plus the followings:
• Anthrax
• Shingles (Herpes Zoster)
• Yellow fever
• A malaria vaccine is under trial.

Preventing Common Cold and Flu

The common cold and flu are respiratory disorders that are caused by different viruses.  The two types of illnesses have similar symptoms.  In general, the flu is worse than common cold.  There is a vaccine for flu but not for common cold.  The primary way in which the cold and flu viruses are spread is in air borne droplets from an infected person’s cough or sneeze.  When your child is sick, keep him/her home from school to avoid spreading the infection.  To reduce the risk of your children getting a cold or flu, teach them the following precautions and habits:

• Cover your nose and mouth when you cough or sneeze.
• Wash your hands often with soap and water or alcohol sanitizer.
• Avoid touching your eyes, nose, or mouth.
• Avoid contact with people who are sick.

Preventing Diarrhea and Dehydration

Diarrheal disease is a leading cause of childhood death in the world-especially in the developing countries.  Diarrhea is also a major cause of malnutrition among the children of these countries.  The major causes of diarrhea are contaminated food and water.  Rotavirus and E.coli are the two main causative agents of diarrhea are developing countries.

The most severe threat posed by diarrhea is dehydration.  During a diarrheal episode, water and electrolytes (sodium, chloride, potassium and bicarbonate) are lost.  Dehydration occurs when these losses are not replaced.

The degree of dehydration is rated on a scale of 3.

1. Early dehydration – no sign or symptoms.
2. Moderate dehydration:

• Thirst
• Restlessness or irritable behavior
• Decreased skin elasticity
• Sunken eyes.

3. Severe dehydration

• All the above symptoms become more severe.
• Shock, with diminished consciousness, lack of urine output, cool, moist extremities, a rapid feeble pulse, low or undetectable blood pressure and pale skin.
  

Death can follow severe dehydration if body fluids and electrolytes are not replenished(ORS or IV fluids)in time. 

Treatment

You have to replace water and electrolytes with Oral Rehydration Salts (ORS or ORT) or through an intravenous drip.

Prevention:

• Continue breast feeding as long as possible = 9-12 months or longer.
• When mixing baby formula used boiled water.
• Wash fruits, vegetables thoroughly before cooking.
• Cook all the fish, poultry and meat well.
• Give only pasteurized milk and drink to children. No raw milk.
• Children should wash their hands after going to toilets and before eating.
• People who handle food should frequently wash their hands with soap and water.
• Refrigerate leftover food promptly.
• Avoid street food.
  

Vaccine

Rotavirus is the main cause of diarrhea and dehydration among children 6 -24 months. Vaccines against rotaviruses are available.  The vaccine is effective.  Get your children vaccinated for rotaviruses.  Currently, two oral, rotavirus vaccines are available.

Parasitic diseases

Approximately 2 billion people are infected with soil-transmitted parasitic diseases worldwide.  It is a common infection in children in developing countries.  Safe and effective medicines are available to control the infection.

The main species of parasites that infect children and adults are roundworm, the hook worm, the pin worm, and the whip worm.

Transmission

Eggs of these parasites are passed in the feces of the infected people.  Adult worms live in the intestine where they produce thousands of eggs each day.  In areas that lack adequate sanitation (like outdoor defecation), these eggs which are passed in the stools, infect the soil.  These eggs can be ingested by children and adults in following ways:

• Eggs that are attached to vegetables (growing close to the soil) are ingested when the vegetables are not washed, peeled and fully cooked.
• Eggs are ingested from contaminated water sources.
• Eggs are ingested by children who play in the contaminated soil and then put their hands in their mouth without washing them.

In addition, hook worm eggs hatch in the soil, releasing larvae that mature into a form that can actively penetrate the skin.  People become infected with hook worm primarily by walking barefoot.  There is no person-to-person transmission of hook worm infection.

Symptoms

The symptoms depend on the number of worms in the body of the infected person.  People with light infections usually have no symptoms.  Heavier infections can cause a range of symptoms including diarrhea, abdominal pain, general malaise and weakness and impaired mental and physical development.  Hook worms which is quite common, cause chronic intestinal blood loss that can result in anemia (low hemoglobin).  One of the most common causes of anemia in children and adults in developing countries is hook worm infection.

Nutritional effects

Soil transmitted parasites impair the nutritional status of the people in multiple ways.

• The worms feed on the tissues of the infected person (host), including blood, which leads to loss of Iron and protein.
• The worms increase malabsorption of nutrients like Vitamin A.
• They cause loss of appetite, diarrhea and dysentery, leading poor nutritional intake and physical fitness.

The nutritional impairment caused by soil-transmitted parasites has a significant impact on the mental and physical development of children. 

Prevention and treatment

• WHO (World Health Organization) recommends periodic medicinal treatment (deworming) of all at risk individuals, especially children in all endemic areas (where infection is common). All the individuals in the area should be treated with deworming medicine once a year and twice a year if the infection rate is more than 50%.
• Health and hygiene education of all the individuals – including children (wearing shoes, washing hands, washing vegetables, cooking them well, drinking safe water etc.)
• Provision of adequate sanitation (toilet) so that people do not defecate outside.

Deworming medicine

The WHO recommended medicines – albendazole (400 mg) and mebendazole (500 mg) – are effective.  They have been extensively used and are safe with no side effects.  It is important that all school children in endemic areas should be dewormed once a year.  They should be also taught the hygiene to avoid getting the infection.

Malaria

Malaria is a life-threatening disease caused by mosquito-borne parasite.  Half of the world’s population (3.2 billion people) is at risk of malaria.  The topic has been discussed in previous chapter.  All children, in endemic area should sleep under a drug-treated mosquito net.  Prevention is better than cure.

The classic symptoms are high fever with chills, rigor, sweats and headache.  They may come and go. Fever may appear every other or every third day.  Pallor and jaundice caused by destruction of the red blood cells may be also present.  Pregnant mother with malaria can pass it on to the baby.

Malaria can be fatal in children.  Every year millions of children die from malaria.  If in doubt seek prompt treatment.

Saheb Sahu, M.D., F.A.A.P., MPH.

Chapter – 6 

A Healthy Pregnancy 

Warning! Drinking alcohol before pregnancy can cause pregnancy.

• Unknown author

You should start taking care of yourself long before you start trying to get pregnant.  For some women, getting their body ready for pregnancy takes a few months.  For other women, it might take longer.

Every day, according to World Health Organization, 800 women die from preventable causes related to pregnancy and childbirth.  99% of these deaths occur in developing countries.  Maternal death is higher in women living in rural areas and poor communities.  Young adolescents (under 15) face a higher risk of complications and death as a result of pregnancy than other women.  Most of these deaths are preventable.

Why do women die?

Women die as a result of complications during pregnancy and following child birth.  The major complications that account for nearly 75% of all maternal deaths are:

• Severe bleeding (mostly bleeding after “childbirth”).
• Infection (usually after childbirth)
• High blood pressure during pregnancy (pre-eclampsia and eclampsia).
• Complications from delivery.
• Unsafe abortion.

The remainders are caused by associated with diseases such as malaria and AIDS during pregnancy (WHO).

Whether this is your first, second or third baby, it is important to take certain steps, before, during and after pregnancy.  Here are some steps you can take.

• Eat a healthy diet – including plenty of vegetables (green- for iron), fruits, whole grain and protein.
• Exercise regularly – at least 30 minutes / day, most of the days of the week.
• Consume 400 micrograms of folic acid (it prevents birth defect) or take a prenatal vitamin daily that contains folic acid and iron.
• Stop smoking if you smoke. Smoking leads to smaller size baby.
• Stop drinking alcohol. Drinking during pregnancy can cause fetal alcohol syndrome (growth retardation, heart defect, cleft palate, abnormal facial features).
• Do not do illegal drugs – they can cause miscarriage, low birth weight and premature birth.
• Make sure you have taken all your vaccinations – like rubella, chicken pox, tetanus.

Regular prenatal care

Prenatal care refers to the regular medical checkups that a women has throughout the nine months of pregnancy.  With regular prenatal care, you can reduce your baby’s risk for potentially serious health problems.  During prenatal visits, your doctor will monitor the status of your pregnancy (how far along), how the fetus is growing, your blood pressure and weight, presence of protein and sugar in your urine (for pre-eclampsia and diabetes) and will prescribe your prenatal vitamins.  It is important that you see your doctor or nurse regularly until you deliver.

Screening tests

Screening tests evaluate the risk of having a baby with certain birth defects.  Women over age of 35 have a higher risk of having high blood pressure, diabetes (gestational diabetes), and miscarriage, still birth and birth defect like Down syndrome.  The common screening tests used in pregnancy include ultrasound and certain blood tests to detect birth defect.

Healthy eating for a healthy pregnancy

While you are pregnant, you will need additional nutrients to keep you and your baby healthy.  But this does not mean you need to eat twice as much.  You should eat only about an extra 300 calories per day (1 cup of cooked rice = 200 calories). Don’t go on a diet during pregnancy, because your fetus might not get enough of the essential nutrients such as protein, vitamins, and minerals.  To help ensure that you are getting enough nutrients, you should take a prenatal vitamin and eat a wide variety of healthy foods every day.

• Fruits and Vegetables

Try to eat 7 serving of fruits and vegetables (3 fruits + 4 vegetables every day).

• Whole grains

Try to eat 6-9 serving of whole-grain or enriched bread and cereals every day.

• Dairy products

Try to eat 3-4 serving of milk and milk products each day (milk, yogurt, cheese).  Dairy products are good sources of Vitamin A and D, protein and vitamin B.

• Protein

Pregnant women should get enough protein – 50 grams per day.  Protein – rich foods have vitamins and irons.  Eggs, milk products, nuts, beans, peas, fish and meats are good sources of protein.

• Folic acid

Pregnant woman need 400 micrograms of folic acid every day to help prevent birth defects such as spina bifida, cleft lip, and congenital heart disease.  Orange juice, spinach, and legumes are good sources of folic acid.

• Iron

Pregnant women need twice as much iron as other women.  The fetus needs iron from the mother to make blood cells.  Too little iron can cause anemia – which is quite common among pregnant women in developing countries.  Good sources of iron are – meat, fish, poultry, dried fruits and iron – fortified cereals.

• Calcium

Pregnant women should get 1,000 milligrams of calcium a day.  Milk and milk products (cheese, yogurt), green leafy vegetables and calcium fortified milk and cereals are good sources of calcium.  Calcium is needed for the bone growth of the fetus.

Most of the time, it is easier to take a prenatal tablet or capsule containing enough of folic acid, iron, and multi vitamins.

How much weight should you gain during pregnancy?

The amount of weight you should gain depends on your weight before you became pregnant and your height.  Most doctors recommend an average weight gain of 20 to 25 lbs. (9 to 12 Kg.) during pregnancy.  If you were underweight before becoming pregnant, you can gain little more.

Exercise and Pregnancy

When you are pregnant, exercise is one of the best things you can do for your physical, emotional and the health during your pregnancy.

• Exercise can help ease and prevent the aches and pains of pregnancy including backaches and exhaustion.
• Active women seem to be better prepared for labor and delivery. The recover more quickly.
• Exercise may lower the risk of high blood pressure and diabetes during pregnancy.
• Fit women have an easier time getting back to a healthy weight after delivery.
• Regular exercise improves sleep during pregnancy.

Low-impact exercise that produces moderate exertion is the best type of physical activity while you are pregnant.

For the best pregnancy out-come, get regular pre-natal care, eat a healthy diet, take prenatal vitamins and Iron, do moderate intensity exercise, and deliver your baby in a hospital.  Even normal pregnancy can go wrong at the last moments, especially at the time of the delivery.  A baby who is deprived of oxygen even for few minutes can die or develop long-term neurological problems. There should be skilled personnel available to take care of the baby, immediately after birth (like resuscitation – oxygen, intubation, and breathing).  Time is critical.  Don’t take chance.  Deliver your baby where skilled personnel are available – both for the pregnant mother and the new born baby.

Saheb Sahu, M.D., F.A.A.P., MPH.

Part Three

Health

Health is a state of complete physical, mental and social well – being and not merely the absence of disease or infirmity.

-World Health Organization

Chapter – 4

Preventing Infections 

Infections are caused by microorganisms – including bacteria, viruses, and protozoa (worms) – that can invade the body and multiply inside.  Out immune system attacks them with white blood cells and antibodies.  The symptoms we have from infections – such as fever, pain and redness, swelling – are the result of immune – system response.

The steps you need to take to prevent an infection depend on how the infection is spread.

Food borne illnesses

Unsafe food, (containing harmful bacteria, viruses, parasites or chemical substances), causes more than 200 diseases (WHO) – ranging from diarrhea to cancer.  It is estimated that one in ten people in the world – fall ill after eating contaminated food. Diarrheal diseases are the most common illnesses resulting from consumption of contaminated food.

• Bacteria
• Salmonella, Campylobacter and E-coli are the moist common bacteria that infect millions of people. They cause nausea, vomiting, diarrhea, abdominal pain and fever.  Salmonella comes from raw egg, poultry and other products of animal origin.  Campylobacter infections are mainly caused by raw milk, raw or under cooked poultry and contaminated drinking water. E.coli is associated with unpasteurized milk, contaminated water, under cooked meat and fresh fruits and vegetables.  coliis found in human and animal feces and urine.
• Listeria

Listeria is found in unpasteurized dairy products.  Listeria infection leads to abortion in pregnant women or death of new born babies.

• Vibrio Cholera

Cholera bacteria infect people through contaminated water or food.  Symptoms include abdominal pain, vomiting and profuse watery diarrhea, which may lead to severe dehydration and death.

• Viruses

Norovirus, Rotavirus, Norwalk virus and other viruses can cause nausea, explosive vomiting, watery diarrhea and abdominal pain.  Hepatitis A can cause jaundice and liver disease.  These viruses typically spread through raw or under cooked food.  Infected food handlers are often the source of food contamination.

• Parasites

Some parasites such as Entamoeba histolytica (amoeba) or Giardia enter the food chain via water or soil and can contaminate fresh produce.  Tape worm, round worm may infect through water, or fresh produce or direct contact.

Rotavirus and E-coli are the two most common agents of diarrhea in developing countries.

Prevention

• Safe drinking water.
• Improved sanitation – no outdoor defecation.
• Hand washing with soap and water – before handling food.
• Drinking and eating only pasteurized milk products.
• Eating well cooked food – especial meat and poultry.
• Washing fruits thoroughly before eating.
• Washing vegetables well and cooking them well.
• Refrigerating leftover food promptly. Bacteria can grow quickly at room temperature.

 Common Cold and Flu 

The Common Cold

Sneezing, a scratchy throat, a running nose – everyone is familiar with the first signs of a cold.  Most colds are mild, lasting from one to two weeks.  Children have six to ten cold a year on average.  One reason colds are so common in children is that they are often in close contact with other children in a day care centers and schools.  On average, people older than 60 have fewer cold a year, because of their immunity.  In most countries, most colds occur during the fall and winter.

More than 200 different viruses are known to cause common cold.  Colds always spread from one person to another.  You cannot get cold from exposure to cold weather or from bathing in cold water.  Some research suggests that psychological stress and allergy of the nose and throat can increase the risk for cold.

There is no treatment for cold.  If you treat it will last 7 days and if you do not it will last for a week (it is a common saying among doctors).

Prevention:

Here are some steps you can take to avoid getting cold or passing a cold to others.

• Wash your hands often with soap and water. When water is not available, use an alcohol based hand sanitizer.
• Keep your hands away from your eyes, mouth and nose.
• If you have cold, avoid getting close to people.
• If you sneeze or cough, cover your nose and mouth, and then wash your hands.
  

Influenza (Flu)

Influenza or flu for short is a very contagious infection that causes high fever, chills, a dry cough, sore throat, running or stuffy nose, headache, muscle aches, and extreme fatigue.  The flu is more severe and long-lasting than a cold.  It can belife-threatening in infants, older adults and people with respiratory problems such as asthma or chronic bronchitis (COPD).

Flu Types

There are two main types of influenza (flu) virus: Type A and B.  The influenza A and B viruses that routinely spread in people are responsible for seasonal flu epidemics each year.  There are also many subtypes of A and B viruses causing flu.  The viruses also change from year to year – hence some year flu shots are not as effective as they should be.

Influenza Symptoms

The flu is different from cold.  The flu usually comes on suddenly. People who have the flu often feel some or all of these symptoms.

• Fever or feverish / chills
• Cough
• Sore throat
• Runny or stuffy nose
• Muscle or body aches
• Headache
• Fatigue (tiredness)
• Some people may have vomiting and diarrhea, though this is more common in children than adults.

It is important to note that not everyone with flu will have a fever.

Flu Complications

Most people with flu will recover in a few days to less than two weeks.  Some people can develop complications (such as pneumonia), and some of which can be life – threatening and result in death.  Pneumonia, bronchitis, sinus and ear infections are examples of complications from flu.  The flu can make chronic health problems worse.  For example, people with asthma may experience asthma attacks while they have flu.  People with chronic congestive heart failure may experience worsening of this condition that is triggered by the flu.  Older people, infants and people with certain chronic medical conditions (such as asthma, diabetes, or heart disease) can develop serious flu – related complication and can die from it.

Prevention

Flu viruses are spread mainly by droplets made when people with flu cough, sneeze or talk.  The droplets can go up to 6 feet.  To avoid flu:

• Stay away from sick people and stay home if sick.
• Wash your hands often with soap and water or sanitizer.
• Keep your hands away from your nose, mouth and eyes if you have flu.
• If you sneeze or cough, cover your mouth and wash your hands.

Vaccination

Flu viruses change from year to year, which is why you need to take your flu shot every year.  To give your body time to build up immunity, take your flu shot between September and mid-November, before flu season starts.  Side effects from flu shots are mild – soreness, redness, or swelling of the site of the shot.  You should not get the vaccination if you are highly allergic to egg or latex (components of the vaccine).

Pneumonia

Pneumonia is an infection of the lungs that can cause mild to severe illness in people of all ages.  It is the leading cause of death in children younger than 5 years of age worldwide.  However, these infections can be prevented with vaccines and can usually be treated with drugs.  Common signs of pneumonia include cough, fever, and difficulty in breathing.  You are more likely to become ill with pneumonia if you smoke or have underlying medical conditions, such as diabetes or heart disease.

Common Causes of Pneumonia

Pneumonia can be caused by viruses, bacteria, and fungi. Common causes of viral pneumonia are influenza and respiratory syncytial virus (RSV).Common cause of bacterial pneumonia is streptococcus pneumoniae.  Pneumonia can also be caused as a result of being on ventilator (respirator – or breathing machine).  This is known as ventilator – associated pneumonia.  Whooping cough, measles, hemophilus, and chickenpox can cause pneumonia in children and lead to death especially among under nourished children.

Prevention

There are several vaccines that prevent infection by bacteria or viruses that may cause pneumonia.  These are:

• Pneumococcal
• HemophilusInfluenza types type-b (Hib)
• Pertussis (whooping cough)
• Varicella (Chicken pox)
• Measles
• Influenza (Flu)

People older than 65 should get pneumococcal vaccine (once only) and yearly flu shots.  All children should be vaccinated against Hemophilus Influenza (Hib), whooping cough, chickenpox and measles. 

Malaria

Malaria is a life-threatening disease that is transmitted to people through the bites of infected female mosquitoes.  About 3.2 billion people-almost half of the world’s population – are at risk of malaria.  Young children, pregnant women and non-immune travelers from malaria free areas are particularly vulnerable to the disease.  Malaria is preventable and curable.

Causative Agent

Malaria is caused by Plasmodium parasites.  The parasites are spread to people though the bites of infected female Anopheles mosquitoes, called “malaria vectors”.  There are five parasites species that cause malaria in humans.  Two of these species – P. falciparum and P. Vivax – pose the greatest threat.  P. falciparum is the most prevalent in African continent.  It is responsible for most malaria – related death globally.

1. Vivax has a wider distribution and predominates in many countries outside of Africa – Asia. SE. Asia, South America.

Symptoms

Malaria is an acute febrile illness.  Symptoms appear 7-15 days after the infective mosquito bite.  The first symptoms – fever, headache, chills and vomiting – may be mild and difficult to recognize as malaria.  If not treated within 24 hours, P. falciparum malaria can progress to severe illness, often leading to death.  Children with severe malaria frequently develop severe anemia and / or breathing difficulty.  In adults, multi-organ involvement is also frequent.  Multi-organs failure from malaria can lead to death.

Who is at risk?

In 2015, approximately 3-2 billion people – nearly half of the world’s population – were at risk of malaria.  Most malaria cases and deaths occur in sub-Saharan Africa.  However, people inAsia, Latin America, and to a lesser extent the Middle East and parts of Europe are also at risk (WHO).

Prevention

Mosquitoes control is the way to prevent and reduce malaria transmission.

Insecticide – treated mosquito nets (ITNs).  Long-lasting insecticidal nets (LLIN) are the preferred form of mosquito nets that should be used by all at risk.

Indoor spraying

Indoor residual spraying with insecticides is powerful way to rapidly reduce malaria transmission.  Its full potential is realized when at least 80% of houses in targeted areas are sprayed.  Indoor spraying is effective for 3-6 months.

Antimalarial Medicines

Antimalarial medicines can be used to prevent malaria.  For travelers, malaria can be prevented through chemoprophylaxis (medicine), which suppresses the blood stage of malaria infections, thereby preventing disease.

Many parts of the world, sub-Sahara Africa and India, mosquitoes are being resistance to insecticides.  The use of 2 different insecticides in treating mosquito net is being recommended for these areas.

Diagnosis and Treatment

Early diagnosis and treatment of malaria reduces disease and prevents death.  It also contributes to reducing malaria transmission.  Resistance to anti-malarial medicines is a recurring problem.

Vaccine against malaria

There are currently no licensed vaccines against malaria or any other human parasite.  One research vaccine against P. falciparum is being evaluated in a large clinical trial in 7 African countries.  It seems to be working.

Tuberculosis

Tuberculosis (TB) is a top infectious disease killer worldwide.  In 2014, close to 10 million people fell ill with TB and 1.5 million died from the disease.  Over 95% of TB deaths occur in low – and middle – income countries.  TB is the leading killer of HIV – positive people.

Tuberculosis (TB) is caused by bacteria (Mycobacterium tuberculosis) that most often affect the lungs.  TB is curable and preventable.

How does TB spread?

TB is spread from person to person though the air.  When people with lung TB cough, sneeze or spit, they propel the TB germs into the air.  A person needs to inhale only a few of these germs to become infected.  People infected with TB bacteria have a 10% life time risk of falling ill.  However, persons with compromised immune systems, such as HIV/AIDS, malnutrition or diabetes, or smokers, have much higher risk of falling ill.  People with active TB can infect 10-15 other people though close contact over the course of a year.

About one-third of the world’s population has latent TB, which means; they have the TB bacteria but are not (yet) ill.  They cannot transmit the disease.

Who is most at risk?

• People who are immune compromised like HIV/AIDS.
• All households’ members and co-workers of a TB patient.
• Children, especially malnourished one.
• Tobacco smokers
• People with diabetes.

Symptoms and diagnosis

• Cough with sputum and blood at times.
• Chest pains
• Weakness
• Weight loss
• Fever and night sweats

A trained laboratory technician can look at the sputum samples under a microscope to see TB bacteria and can make the diagnosis.  Chest x-ray can also help in the diagnosis.  The diagnosis can be made within 24 hours, but this test does not detect numerous cases of less infectious forms of TB.  Tuberculosis is particularly difficult to diagnose in children.

Treatment

TB is a treatable and curable disease.  Active non drug resistant TB is treated with a standard 6 months course of 4 drugs.  The vast majority of TB cases can be cured when medicines are provided freely and taken properly.  Disease caused by standard drug resistance TB bacteria (MDR-TB) is treatable and curable by using a second line of drug.

Sexually Transmitted Disease (STDS)

Sexually transmitted diseases or infections (STD or STI) are contagious infections that can be passed from person to person through sexual intercourse or other sexual contact, including oral and anal sex.  Many of the organisms that transmit STDs can live on the penis, vagina, anus, mouth, and nearby skin surfaces.  Some STDs can also be transmitted through non sexual contact with infected tissues or fluids, such as infected blood.  For example, intravenous drug users can acquire HIV or hepatitis B from sharing needles.  HIV and hepatitis B can also be transmitted from the mother to a fetus during pregnancy.

Causative Agents

More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact.  Of these 8 infections, 4 are curable: syphilis, gonorrhea, chlamydia and trichomoniasis.  The other 4 are viral infections and are not curable: hepatitis B, herpes simplex virus (HSV or herpes), human papilloma virus (HPV) and HIV. Symptoms or disease due to the incurable viral infections can be reduced or modified through treatment.

Symptoms

A person can have STDS without having obvious symptoms of disease.  Common symptoms of STDS are:

• Vaginal discharge.
• Urethral discharge or burning in men
• Genital ulcers
• Abdominal pain

Complications

STDs can have serious consequences beyond the immediate impact of the infection itself.

• Mother to child transmission can result in still birth, premature birth, new born death, infection and congenital deformities.
• STDs can increase the risk of HIV infections.
• STDs such gonorrhea and chlamydia are major causes of pelvic inflammatory disease (PID) and infertility in women.
• Human papilloma virus (HPV) infection causes cervical cancer – and death in women and mouth and throat cancer in both men and women.

Prevention

• Don’t have multiple sex partners. Having multiple sex partners exponentially raises your risk of STDs.
• Use condom (male or female) from start to finish of sexual activity.
• Don’t have sex with intravenous drug users – risk of hepatitis B and HIV are very high.
• Be in a committed relationship and know the STD status of your partner.
• Take precaution during pregnancy.
• Tests for STDs are inexpensive and are easily available. Effective treatment is currently available for several STDs. If in doubt get tested.

You cannot avoid STDs by washing your genital area, urinating, or douching after sex.  Keep in mind that you can still acquire and transmit STDs, even if you use a condom, because a condom does not cover the surrounding skin areas.

HIV / AIDS

Human Immunodeficiency Virus (HIV) causes AIDS (Acquired Immuno Deficiency Syndrome). HIV virus attacks the cells of the immune system, leaving a person vulnerable to life-threatening infections and cancers.  Without treatment, AIDS is usually fatal.  HIV continues to be a major global public health issue, having claimed 1.6 million lives in 2014.

Transmission

HIV can be transmitted via the exchange of a variety of body fluids from infected individuals, such as blood, semen and vaginal secretions and breast milk. Individuals cannot become infected though ordinary day to day contact such as kissing, hugging or shaking hands. 

Risk Factors

Behaviors and conditions that put individuals at greater risk of contracting HIV include:

• Having unprotected oral or vaginal or anal sex.
• Having STDs such as syphilis, herpes, gonorrhea, and chlamydia.
• Sharing contaminated needles, syringes.
• Receiving unsafe injections, blood transfusions, medical procedures that involve unsterile cutting or piercing.
• Experiencing accidental needle stick injuries – including among health workers.

Diagnosis

Most individuals develop antibodies to HIV within 28 days but antibodies may not be detectable early after infection.  HIV infections can be detected with great accuracy after 28 days.

Prevention

Individuals can reduce the risk of HIV infection by limiting exposure to risk factors.

• Male and Female Condom use. Male latex condoms have 85% or greater protective effect against HIV and other STDs.

• Testing and counseling for HIV and STDs.

Testing for HIV and other STDs is strongly advised for all people exposed to any of the risk factors.  By getting tested people learn their own status and seek necessary treatments.  TB is the most common presenting illness among people with HIV.  Early detection of TB and prompt treatment for both (TB + HIV) will save life.

• Male Circumcision

Medical male circumcision, when safely done, reduces the risk HIV infection in men by 60%.

• Antiretroviral treatments(ART) use for prevention

Pre-exposure prophylaxis (PREP) is the use of ART drugs within 72 hours of exposure to HIV in order to prevent infection.  It works.

• Elimination of mother-to-child transmission of HIV

The transmission of HIV from an HIV-positive mother to her child during pregnancy, labor, delivery or breastfeeding is called vertical transmission or mother-to-child transmission (MTCT).  Mother to child transmissioncan be prevented if both the mother and the child are treated with ART.

• Safe needle use

People who inject drugs (addicted drug users) can take precautions against becoming infected with HIV by using sterile needles and syringes.

Between 2000 and 2015, new HIV infections have fallen by 35% and AIDS – related death have fallen by 24%.

Hepatitis

A number of viruses can cause hepatitis.  Hepatitis is an inflammation of the liver. 

Hepatitis – B

Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic liver disease.  The virus is transmitted through contact with the blood or other body fluids of an infected person.  It is a major global health problem.  It can cause chronic infection and puts people at high risk of death from liver failure and liver cancer.  An effective vaccine against hepatitis B has been available since 1982.

Transmission

The hepatitis B virus can survive outside the body for at least 7 days.  The incubation period of hepatitis B virus is 75 days on average, but can vary from 30 to 180 days.  The virus may be detected within 30 to 60 days after infection.  Hepatitis B is transmitted the following ways:

• Mother to child at birth.
• Expose to infected blood – blood transfusion.
• Various body fluids – blood, saliva, menstrual, vaginal, and semen (sexual).
• Use of infected needles, syringes and unsterilized medical instruments.
• Infection can occur during medical, surgical, dental procedures, tattooing or razors.

Symptoms

In many cases, a hepatitis B infection produces no symptom.  However, some people have acute illness with symptoms that last several weeks.  They can include jaundice (yellow discoloration of skin and eyes), feeling tired, loss of appetite, nausea, abdominal discomfort, dark urine, gray – colored stools, and joint pain.  More than 90% of healthy adults who are infected with the hepatitis B virus will recover naturally from the virus within the first year.

Diagnosis

It is not possible to differentiate hepatitis B infection from other forms of hepatitis.  However a number of blood tests are available to diagnose and monitor people with hepatitis B.  They can be used to distinguish between acute and chronic infections.

Treatment

There is no specific treatment for acute hepatitis B.  Chronic hepatitis B infection can be treated with antiviral drugs.  Treatment can slow the progression of liver damage (cirrhosis), reduce incidence of liver cancer and improve survival.  However, in most people, the treatment does not cure hepatitis B infection.  The treatment is life-long and very expensive.

Prevention – Vaccination

The most effective way to prevent hepatitis B is to have the hepatitis B vaccination.  The three-dose vaccine is 95% effective in preventing infection and the development of chronic liver disease and liver cancer due to hepatitis B.  The vaccination is recommended for all infants and children, and adults who are at risk (such as health care workers) for hepatitis B infection. Using latex condoms correctly and consistently may help reduce the risk of transmission during sexual activity.

Hepatitis A

Hepatitis A is viral liver disease that can cause mild to severe liver disease.   The hepatitis A virus is transmitted through ingestion of contaminated food and water or through direct contact with an infected person.  Most people recover fully from hepatitis A.  Unlike hepatitis B and C, hepatitis A infection does not cause chronic liver disease and rarely fatal.  The disease is common in all the developing countries.

Transmission

The hepatitis A virus is transmitted primarily by the fecal-oral route; that is when an uninfected person ingests food or water that has been contaminated with the faces of an infected person.  Water borne out breaks, though frequent, are usually associated with sewage – contaminated or inadequately treated water.  The virus can also be transmitted through close physical contact with an infectious person.  Casual contact among people does not spread the virus.

Symptoms

The incubation period (that is the time between the infection and the start of the symptom) of hepatitis A is usually 14-28 days.  Symptoms of hepatitis A range from mild to severe, and can include fever, malaise, loss of appetite, nausea, abdominal discomfort, jaundice (a yellowing of the skin and whites of the eyes and dark – colored urine.  Not everyone who is infected will have all of the symptoms.  Infected children under 6 years of age do not usually experience noticeable symptoms, and only 10% develop jaundice. 

Who is at risk?

Anyone who has not been vaccinated or previously infected can contract hepatitis A.  Risk factors include:

• Poor sanitation;
• Lack of safe water;
• Living in a household with an infected person;
• Being sexual partner of someone with acute hepatitis A infection;
• Travelling to areas where hepatitis A is common;
• Being a child or worker in a day care center.

Diagnosis

Cases of hepatitis A are not medically distinguishable from other types of acute viral hepatitis.  Diagnosis can be made by detection of hepatitis antibodies in the blood.

Prevention

The spread of hepatitis A can be reduced by:

• Adequate supply of safe drinking water.
• Proper disposal of sewage within communities and
• Personal hygiene such as regular hand-washing with uncontaminated water.

Vaccination

Several hepatitis A vaccines are available.  The two-shot vaccination against hepatitis A is quite effective.  All people at risk or all people travelling to countries where hepatitis A is common should get the vaccine.

Hepatitis C, D and E

Hepatitis C is spread through blood and blood products and contaminated needles.  The majority of people with acute hepatitis C are without symptoms.  The hepatitis D virus survives and multiplies by attaching itself to the hepatitis B virus. It is common in drug users. Hepatitis E is a food – borne virus similar to hepatitis A.  It is common in Asia and South America.

Saheb Sahu, M.D., F.A.A.P., MPH.

Chapter 3

Body Weight 

I want to weigh less, not through diet and exercise, but by acquiring a faulty scale.

• Jarod Kintz

Body Mass Index (BMI) 

Body Mass Index is used by doctors to define normal, over weight and obesity.  BMI does not directly measure the percent of body fat, but it is a better indicator of obesity than weight alone.  BMI is calculated by dividing a person’s weight in kilograms by the square of his/her height in meters (Wt. in Kg/ht. in (m²).  Just look up your BMI on the table below or go to a website like CDC.gov or bmisite.net.  It is important that you know your present BMI.

BMI                                                    Status

Below 18.5                                        Underweight

18.5 – 24.9                                        Normal weight

25 – 29.9                                            Overweight

30 or higher                                      Obese

Newer studies show that normal BMI for Asian is up to 23 instead 24.9.

Rule of Thumb for Ideal Body Weight 

Ideal Bodyweight in Kilogram (IBW) for male = I Height in Centimeter – 100

For Female = Ht. in Centimeter – 105

For example a 168 cm. tall male weighs 77 Kg. His ideal body wt. should be = 168 – 100 = 66 Kg.

Another rule of thumb is, your adult weight should be the same as your high school graduation weight.

Waist Circumference (WC)

It is important to know not only how much fat you have on your body, but also where the fat is located.  Women typically collect fat in their hips and buttocks; men tend to collect in their bellies (abdomen).  Excessive abdominal fat places you at greater risk for developing obesity – related conditions like – type-2 diabetes, high blood pressure, heart disease and stroke.  For Indian men the waist circumference should be less than 78 cm. and for women less than 72 cm. (International Journal for obesity 2005).  If you have a bulging stomach (belly), it means you have too much abdominal fat and you are at risk for obesity – related diseases.

The Health Effects of Overweight and Obesity

People who are obese, compared to those with a normal weight, are at increased risk for many serious diseases and health conditions, including the followings:

• All – causes of death (mortality)
• High blood pressure (Hypertension)
• Type 2 diabetes
• High LDL (Bad) cholesterol, low HDL (good) cholesterol, or high levels of triglycerides (Dyslipidemia).
• Coronary heart disease (heart disease)
• Stroke
• Gall bladder disease
• Osteoarthritis (a breakdown of Cartilage and bone within a joint) (Arthritis).
• Some Cancers – endometrial, breast, colon, kidney, gallbladder and liver.
• Body pain and difficulty with physical activity.
• Mental illness such as depression, anxiety and other mental disorders.
• Low quality of life. *(CDC).

Losing Weight

It’s natural for anyone trying to lose weight to want to lose it very quickly.  But evidence shows that people who lose weight gradually and steadily (about 1 to 2 pounds (0.45 to 0.9 kg) per week are more successful at keeping weight off.  Healthy weight loss is not just about a “diet” or “program”.  It is about an ongoing life style that includes long – term changes in daily eating and exercise habits.

To lose weight, you must use up more calories than you take.  Since one pound (0.45 kg) equals, 3,50 calories you need to reduce our caloric intake by 600 -1000 calories per day to lose about 1to 2 pounds (0.45 – 9 kg) per week.

Once you have reached a healthy weight, do physical activity of moderate intensity, 60 to 90 minutes most of the days of the week.  By eating a reasonable lower caloric healthy diet and daily exercise, you are more likely to be successful at keeping the weight off over the long run.

Losing weight is not easy, and it takes commitment.  But keeping off is much harder.

Even Modest Weight Loss Can Mean Big Benefits

The god news is that no matter what your weight loss goal is, even a modest weight loss (5 to 10 lbs. – 2 to 4 kg), is likely to produce health benefits, such as lowering of blood pressure, blood cholesterol, and blood sugars. 

Tips for Healthy Weight Loss

• Set goals.
• Eat slowly.
• Use smaller plates.
• Donot skip meal – eat 3 – 4 small meals a day and eat low caloric snacks.
• Eat a diet with whole grains, lots of fruits and vegetables, low fat dairy products, less processed foods, less sugar and trans fats and some nuts.
• Get at least 30 minutes of moderate – intensity physical activity daily.

The Downside of Dieting

Dieting can increase your risk of developing gall stones.  People who lose a large amount of weight quickly (more than 3 lbs. – 1.5 kg) a week, are at greater risk of gallstones than those who lose weight more slowly.  Quitting smoking becomes more difficult when you have to contend with possible weight gain that happens to many people who quit.  Yo – yo dieting (losing and gaining weight ) also can pose some health risks like – gall stones, high blood pressure, abnormal blood cholesterol and possible damage to the immune system.

The key to achieving and maintaining a healthy weight is not about short – term dietary changes.  It is about a lifestyle that includes healthy eating, regular physical activity, and balancing the number of calories you consume with the number of calories your body uses.  Staying in control of your weight contributes to good health now and as you age.

Saheb Sahu, M.D., F.A.A.P., MPH.