High-grade Fever with Pain in Tummy and Vomiting: May be Typhoid

Cases of typhoid fever are up during rainy season due to poor public health measures. Sanitation-wise filthy cities, uncovered and unwashed food stuffs are hazardous for travelers since typhoid infection is food borne. Typhoid fever is caused by bacteria known as Salmonella typhi or Salmonella paratyphi. There are two strains of Salmonella paratyphi, known as Salmonella paratyphi-A & Salmonella paratyphi-B. High-grade fever with pain in tummy associated with vomiting may be typhoid. Fever may rise upto 106^o F creating a scare in the family but never panic and call a physician or take the patient to the hospital. For an accurate diagnosis, germs of typhoid can be grown from the blood (Blood Culture Test) of the patient. However, there are some viral fevers which may mimic the symptoms of typhoid. If untreated, typhoid may lead to dire complications like perforation of intestine, hemorrhage (bleeding) and sudden bacterial shock. My contention is not to horrify people by citing the manifestations of this disease but spread awareness about prevention and timely treatment of it.

Science has enabled us to diagnose and treat typhoid effectively with antibiotics. Patient may be treated at home or at a hospital. But complete course of the recommended antibiotics should be taken to avoid relapse. Other members of Salmonella family (Salmonella paratyphi-A & Salmonella paratyphi-B) producing paratyphoid fevers and food-poisoning can also be treated well with antibiotics. Bacteria of Salmonella family are facultative bacteria and carriers of the disease continue passing the germs in their stool and urine.

Prevention is always better than cure and till we catch-up on community prevention; individual prophylaxis has to be very tight through vaccination. TAB vaccine is used worldwide to acquire protection against bacteria of Salmonella family. A variety of antibiotics are available to treat typhoid fever. Many countries have eradicated indigenous typhoid through meticulous and efficient public health measures. However, people traveling abroad are advised to get shots of TAB vaccine and cholera vaccine.

Cholera: Prevention is better than cure

Cholera is a diarrhoeal disease caused by the bacteria known as Vibrio cholerae. The infection leads to a form of diarrhoea in which the patient passes the so called rice-water stool instead of the usual formed faeces. The cause of such stools is now well understood. On entering the human intestine through contaminated food or water, the Vibrio cholerae lodges itself in small intestine. Here it secretes certain proteinaceous substances (known as enterotoxins), which attach to the specific receptors (Gm ganglioside)on the intestinal cell surface. A part of enterotoxin then enters the intestinal epithelial cells and activates the metabolic pathway in them leading to a profuse outpouring of fluids from them into the intestinal lumen. The bacteria themselves, however, do not invade the tissue. The disease had been endemic in India down the centuries, mainly in the Ganges and Brahmputra deltas in Bengal. The record of spread of Cholera throughout the world is available only after 1817 when the first pandemic occurred.  Since then six such pandemics are on record showing that the disease affected millions of people all over the world with high rate of mortality and morbidity. The seventh pandemic spread from the Sulwesi Island in Indonesia in 1961 that was caused by a biotype el Tor of Vibrio cholerae.

The man is the only source of the disease. The spread occurs through a contaminated environment. An infected patient excretes around 10⁷ to 10² bacteria per ml of stool which may further contaminate drinking water through sewage pollution. Wells and reservoirs of surface water (lakes and ponds) can get contaminated easily.  Food is another source of infection. All people in the endemic area should use boiled cooled water for drinking. Food handlers can also act as transmitters of infection. Flies act as mechanical transmitters of Cholera infection. Sanitation staff should be alerted to decontaminate the water-bodies with permitted chemicals.

The clinical picture may range from an asymptomatic carrier state to the fulminant disease. The most characteristic feature is rice-water stool and a precipitate vomiting. Dehydration may develop due to fluid loss and if not treated, the patient may collapse within 24 hours. Tentative diagnosis of disease can be made by the microscopic examination of stool, where a hanging drop preparation on a slide would show darting mobility of the bacteria. The specific diagnosis is made by growing the bacteria on artificial media in the laboratory and by serotyping of bacterial colonies grown on media.

The disease is treated by replacing the lost fluids and electrolytes, intravenously if the patient is admitted to a hospital or orally through oral rehydration powder. Tetracycline is the drug of choice. Sulphonamides, furazolidne and cotrimethoxazole have also been found to be useful. Drugs should never be taken without medical consultation. Cholera is one of the diseases which can be prevented by vaccination controlled by sanitation. The source of infection being man alone and the commonest vehicle of transmission is the water. Special attention should therefore be paid to the purity of water and the ice made from it for human consumption. The disposal of human excreta and garbage should be safe and soiled clothes of the patient must be disinfected. The isolation and treatment of Cholera patients is must. The outbreak of cholera should be notified at national level immediately for adequate prophylactic vaccination of people traveling to that area. The cholera vaccine (vaccine developed from attenuated Vibrio cholerae) is given by intramuscular injection provides effective protection for two to three months in around 89% of vaccinated population. However, oral vaccines of cholera are also available with variable protective efficacy.

Children’s health, growth and immunization: Our role in preventing preventable diseases

Unless we look after our women and children in a programmed manner in the field of health, we cannot have a happy world around us. Children are still killed or disabled each year by diseases that could have been prevented by immunization. The World Health Organization (WHO) is doing its best to eradicate/eliminate a variety of infectious diseases, but involvement of every citizen of the world is must for compliance of various programs of the WHO. The measles, mumps and rubella triple vaccine (MMR) should be included in the EPI (Expanded Preventable Immunization) program of every country. We should not ignore the facts that measles and mumps can cause considerable morbidity and mortality which could be prevented with optimum immunization. Optimum immunization means full course of vaccination schedule without missing any booster dose.

Apart from vaccination child nutrition and general health must be taken care of. The child health reminds me the efforts of Mr. James P Grant, the Director of United Nations' Children's Fund (UNICEF, 1984), who in 1984 brought out a Report on the State of World's Children, and forwarded a mnemonic GOBI-FFF to remember the techniques which could reduce sadness of the world. In GOBI-FFF, "G" stands for growth monitoring, "O" stands for oral rehydration therapy, "B" stands for breastfeeding, and "I" stands for immunization. The three Fs (FFF) stand for 'family spacing', food supplements and female education. The methods represented by GOBI-FFF are the simplest methods which could help us in tiding over the state of health of children and preventing diseases and saving lives. Consequent upon the compliance of GOBI-FFF, lives of millions of children are saved every year and the health and growth of millions more is protected. Still there is need to protect the children from episodes of common childhood diseases like measles, respiratory infections and diarrhoeal infections.

Various infections also interfere with physiological and psychological development of children. The malnutrition and infections perpetuate each other and may lead to suboptimum brain development. The GOBI methods are not so expensive. Community health workers can be assigned the responsibility of growth monitoring through periodic recording of weight and height of a child. The oral rehydration salts (ORS) should be supplied at cost price to prevent the dehydration caused by diarrhoea. The breastfeeding should be encouraged since it provides ideal nourishment to the child and saves from the infectious hazards of bottle feeding. Immunization against tuberculosis, diphtheria, pertusis (whooping cough) tetanus, polio, measles, mums and rubella protects the child against these serious as well as disabling diseases. Attention should also be given to the health education of mothers. Awareness about the child's health in mothers would definitely make all the healthcare and immunization programs successful. It is well established fact that proper spacing between child births decreases the risks to the heath of the mother and the infant. Food supplements should regularly be supplied to the mothers during pregnancy and vaccination against tetanus should be done. We must put in our best efforts to prevent the preventable diseases since prevention is better than cure.

Malaria: Prevention Is Better Than Cure

Malaria could be a serious and life threatening disease if not diagnosed and treated properly. Treatment of malaria had been known to general physicians even before the discovery of causative organism, the Plasmodium, a parasite. The parasite of malaria was discovered by Laveran in 1880 and in 1898, Sir Ronald Ross worked out the mosquito cycle with parasite of birds. There are four known species of malarial parasite causing malaria in human beings. These species are Plasmodium vivax, Plasmodium ovale, Plasmodium falciparum and Plasmodium malariae. Infection is caused by bites of infected female Anopheles mosquitoes. The incubation period for P. vivax and P. ovale is around two weeks, for P. falciparum 8-12 days and for P. malariae incubation period is three to four weeks. The surest way of diagnosing malaria is through microscopic examination of peripheral blood film. Anyone having high grade fever (around 104 to 105^o F) and chills should get tested for malaria. Febrile paroxysm (bout of fever) starts generally in the early afternoon however it may start at any time if mixed infection (infection of two or more malarial parasite species). Malarial parasites of animals (P. berghei of rats and mice, P. knowlesi of monkeys etc) do not infect human beings. Each paroxysm shows a succession of three stages:

1. The cold stage: Lasting 20 minutes to one hour.


2. The hot stage: Lasting one hour to 4 hours.


3. The sweating stage: Lasting 2 to 3 hours.
   

The total duration of the febrile cycle could be from 6 to 10 hours. The febrile cycle may vary with the species of malarial parasite. Malarial parasites are found in all countries extending from 40^o south to 60^o north. The tropical zone is the endemic home of all malarial parasites infecting man. Prevention: Malaria eradication could only be possible through coordinated efforts of the people and the government agencies involved in the control of mosquitoes since malaria is a serious public health problem in all the tropical and subtropical regions of the world. If you go through the pages of the history of science and malaria, you would find that malaria had taken more human lives than any other disease. To control mosquito breeding always keep storage water tanks covered with mosquito tight lids. Larvae eating fish (gambusia or guppy) should be introduced in stagnant water ponds. Insecticides should be sprayed regularly at home, the work place and drains. Use mosquito nets at night and protective clothing during the day time. Consult your physician and take prophylactic medicine if malaria is endemic. Prevention is always better than cure since it saves our money, time and health.