typhoid

Every year, approximately 20 million cases of typhoid fever, and its milder version paratyphoid, occur in World Health Organisation's South East Asia region, which includes India. This results in around a million deaths. The exact Indian statistics are unknown. Although the disease is supposed to be notified to relevant government health authorities when it occurs, this seldom happens. Our illnesses are treated by a plethora of private practitioners of various systems of medicine, with very little networking or government supervision.

This is in stark contrast to the US, which has around 400 cases annually (mostly imported). Even a century ago, the US public health system was very active and backed to the hilt by the police. In 1860, the US had an asymptomatic typhoid carrier nicknamed "typhoid Mary" (actual name: Mary Mallory). She worked in several places as a cook. She did not wash her hands frequently and consequently managed to infect several hundred people and kill 50. She was tracked down and quarantined for more than 20 years till her death. In India, cooks and other labour are unregulated. They do not undergo regular health checkups. Unauthorised food stalls dot the countryside. The servers seldom wear gloves, nor do they wash hands frequently.

Typhoid and paratyphoid bacteria are ingested with contaminated food and water. (Ice cream and cream cakes are notorious). It takes one to three weeks for the symptoms of fatigue, headache, loss of appetite, diarrhoea, a red rash and fever (which starts at around 100°F and then increases to 102°F-104°F) to appear. Complications like intestinal bleeding and perforation occur in the second or third week. (This accounts for the age-old habit of keeping people with fever on a soft and bland diet.)

A history of risk of infection and a gradual onset of fever that increases in severity raise the suspicion of typhoid or paratyphoid fever if the symptoms mentioned earlier are present. Infection with typhoid or paratyphoid fever causes very low-grade septicemia. A single blood culture is positive in only half the cases. Bone marrow culture is positive in about 80 per cent of the cases. Stool and urine cultures become positive later.

Popular tests like the Widal test are unreliable. It can be negative in up to 30 per cent of culture-proven cases of typhoid fever. It can give false positive results if the infection is due to other gram negative organisms, or malaria, typhus or medical conditions like liver cirrhosis. Two blood samples taken a week apart showing a rising Widal titer are more reliable. The newer "Typhidot" tests are more accurate, but need to be done a minimum of five days after the onset of the fever. This is to allow antibodies time to develop.

Typhoid can be treated with a wide range of newer antibiotics. Choloromycetin, the antibiotic widely used earlier, is not popular now as it not only has dangerous side effects but many typhoid bacteria are also resistant to it. Treatment should be continued for 10-14 days and not stopped when the patient is symptomatically better.

After apparent recovery, some people harbour typhoid bacteria in their gall bladder, intestines or kidney. They do not have fever, but continue to shed bacteria in their motion and urine. They are a danger to others as they spread the disease far and wide.

Typhoid can be prevented with immunisation. Both injectable and oral forms of vaccine are available and can be taken after the age of two. Vaccination has to be repeated every three years since immunity wanes after that time.

To protect yourself against food borne diseases like typhoid:

• Drink only boiled or bottled water.
• Do not put ice into drinks unless the ice is made from boiled or mineral water.
• If you eat street food, avoid raw fruits and vegetables
• Eat food that has been thoroughly cooked and is steaming hot

Immunise yourself and your family. The vaccine costs less than Rs 500.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

tuberculosis

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Complete course to cure TB

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Your Health - Dr. Gita Mathai

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March 24 was world tuberculosis (TB) day. Our country has 2.2 million cases of TB out of a global incidence of 8.7 million. The problem in India is compounded by irresponsible individuals who are irregular with treatment or discontinue it. This eventually results in the spread of TB bacteria that are resistant to standard inexpensive medication.

TB is caused by Mycobacterium tuberculosis. It is acquired when a person with lung tuberculosis coughs or spits out bacteria-laden sputum. Once the bacteria is inhaled or ingested, it spreads via blood. It can lodge itself in any organ - lungs, liver, kidney, lymph nodes, gastrointestinal tract, genitourinary tract, nervous system and even the eye. It can cause active infection immediately or remain dormant for a lifetime (latent TB). It can get reactivated, especially if immunity falls owing to other illnesses such as HIV infection, diabetes or cancer.

The symptoms of TB are often vague. There may be low-grade fever (especially in the evenings), sweating, weight loss and a cough, which lasts three weeks or more. There may also be blood-stained sputum or urine, white discharge, diarrhoea, lumps and bumps, enlarged lymph nodes and bony swellings, depending on the organ affected. All these signs and symptoms can occur with other diseases. Lumps may be due to tumour, fever may be due to other infections, and blood-stained sputum can occur in pneumonia, lung abscess or cancer.

If there is blood-stained sputum, it can be examined for TB bacteria. A positive result means that there is TB infection in the lungs. A negative result does not rule it out. The test needs to be repeated at least twice more. TB bacteria from the lungs can be swallowed during sleep. This can be tested by inserting a tube into the stomach and checking the early morning aspirate. Lumps and bumps can be biopsied. The diagnosis may be suspected by the appearance of the affected organs on X-rays or scans.

A skin (Mantoux) test can be done, wherein a small dose of PPD (purified protein derivative) is injected in the skin of the forearm. It is measured 48 to 72 hours later. A negative result does not rule out TB as the test may have been done too early in the disease (before immunity develops), the person may be immuno-compromised or on steroids. Other blood tests are also available like QuantiFERON-TB Gold in-Tube test and T-Spot test. They can also give false positive or negative results.

Once the diagnosis is reached, treatment is started. The duration may be anywhere from six months to one and half years depending on the site (lymph node disease requires shorter treatment whereas that in bone and meninges require longer treatment), the extent of disease, the severity and the response.

Initially, a combination of four first line drugs - Isoniazid, Rifampicin, Pyrazinamide, Ethambutol - and sometimes Streptomycin is used. After some months, the number of drugs (not the dosage) is reduced. Rifampicin needs to be taken on an empty stomach. It can colour the urine and sweat reddish-yellow.

These drugs can be purchased with prescriptions but free treatment is also provided by the government. Patients can opt for whatever suits them personally and financially.

Treatment is complicated by the fact that the bacteria multiplies slowly. If the drug dosage is inadequate or irregular, the bacteria becomes resistant and thrives even with continued administration of medication. Drug-resistant bacteria then develop which have to be treated with expensive second line medication. These unresponsive bacteria can spread in the community.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

10,000 steps a day keep diabetes away

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Your Health - Dr. Gita Mathai

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India has around 70 million diabetics and the number is increasing every day. The disease occurs when the body is not able to keep blood sugar in the normal range. Diabetes is suspected if the blood glucose level is 126 milligrams per decilitre (mg/dL) after an overnight fast, non-fasting glucose level (random) is greater than 200 mg/dL or glucose level is greater than 200 mg/dL two hours after a meal.

The level of glucose in blood is maintained in the normal range by a hormone called insulin, produced by islet cells in the pancreas. Diabetes occurs when there is an absence or relative lack of insulin or if there is peripheral resistance to its action. An absolute lack of insulin occurs if the islet cells are absent or destroyed. This means that insulin has to be externally supplied as injections. A relative lack of insulin is more common; 95 per cent of diabetics fall in this category.

Diabetes is more likely to occur with increasing age; 45 was considered a magic number, with a dramatic increase in the incidence of diabetes after this age. This may be due to a propensity to "settle into prosperous middle age" at this time with an increasingly sedentary lifestyle and over eating.

Resistance to the action of insulin occurs with an increase in the number and size of fat cells. To diagnose obesity, the BMI (weight divided by height in metres squared) should be less than 30, the waist circumference less than 40 inches in men and 34.5 in women, the waist:hip ratio less than 0.9 for men and 0.85 for women.

The tendency to obesity sets in at a young age. Many children do not have the compulsory hour of physical activity daily. Computer games and television occupy their time instead. Weight climbs up and many are frankly obese by the time they are teenagers. As a result of this, diabetes increasingly occurs in adolescents and young adults in their twenties and early thirties as MODY (Maturity Onset Diabetes of the Young).

If one parent has type 2 diabetes, the risk of the offspring getting diabetes is 1 in 7. A mother with type 2 diabetes is more likely to pass it on to her offspring than a father. If both parents are diabetic, the chances of the child eventually developing the disease is 50 per cent.

The environment in which the child grows up can explain much of this. Diabetes is more likely to manifest itself if the family is sedentary, obese and overeats, with unhealthy food habits and a propensity for fat-laden processed or fast food. Mothers usually influence food habits a great deal more than fathers.

High blood pressure is linked to diabetes. A person with one disease often gets the other within a few years. Dyslipidemia - with elevated lipids and an abnormal lipid profile - also increases the risk of diabetes. All the three are linked and this group of biochemical abnormalities is called the "metabolic syndrome X." Unless steps are taken to correct these biochemical abnormalities, diabetes can eventually occur.

Women with PCOS (polycystic ovarian syndrome) often have all the abnormalities of metabolic syndrome X. They also have insulin resistance and obesity. Unless intervention (diet, exercise, metformin) occurs, 50 per cent go on to develop diabetes.

Pregnancy can precipitate a type of diabetes called "gestational diabetes" in a predisposed individual. The sugars usually return to normal values after the delivery. Diabetes may develop a few years later if obesity occurs.

Diet plays a very important role in the control of diabetes. Calories have to be restricted to 1500 or 1800 a day, depending on the level of exercise. Foods have a glycaemic index or GI, which measures how a carbohydrate-containing food raises blood glucose. Food is ranked on the GI scale from 0-100. The glycaemic index of a particular food can be found on the Internet. Food with a high GI raises blood glucose more than food with a medium or low GI. Foods with a low GI include legumes, all non-starchy vegetables, sweet potatoes, most fruit, long grained brown or red rice, and whole grain rotis.

To control diabetes and delay its onset, combine diet with exercise for an hour a day, either at a single go or split into two sessions, or cover 10,000 steps a day.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her atyourhealthgm@yahoo.co.in