 1 HEPATITIS (all)
 2 some more on Hepatitis A
 3 some more on Hepatitis B and D
 4 some more on Hepatitis C
 5 some more on Hepatitis E
 6 some more on Hepatitis G
 7 Leptospirosis (Weil)
 8 Lyme Disease
 9 Malaria
 10 Meningitis - bacterial
 11 Meningitis - viral (Aseptic)
 12 Newcastle disease

\1 HEPATITIS

Hepatitis is a general term for inflammation of the liver. It is a common disease worldwide. The symptoms are fever, chills, headache, fatigue, feelings of weakness and aches and pains, followed by loss of appetite, nausea, vomiting, abdominal pain, dark urine, light- coloured shit, jaundiced (yellow) skin and the whites of the eyes may turn yellow.

Hepatitis is an inflammation of the liver  It is a common disease worldwide. The symptoms are fever, headache, chills, fatigue, feelings of weakness and aches and pains, followed by loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-coloured faeces, jaundiced (yellow) skin and the whites of the eyes may turn yellow.

The diff types of hep are caused by different viruses, but they all produce inflammation of the liver. Viral hep refers to several common contagious diseases that attack the liver. The most important types of viral hep are hep A, B, and C. Newly discovered forms of viral hep also include hep D, E, and G. Non-viral forms of hep can be caused by toxic agents (drugs or chemicals), alcohol, or autoimmune processes. Another form of hep is toxic hep. Toxic hep can be caused by viruses or by liver damage due to toxic substances. Toxic hep is a deterioration of the liver cells caused by chemicals, alcohol, drugs, and industrial compounds. Alcohol abuse is a common cause of toxic liver damage.

 What Is Hepatitis? The liver is the largest organ in the body, occupying the entire upper right quadrant of the abdomen. It performs over 500 vital functions. It processes all of the nutrients the body requires, including proteins, glucose, vitamins, and fats. The liver manufactures bile, the greenish fluid stored in the gall bladder that helps digest fats. One of the liver's major contributions to life is to render harmless potentially toxic substances, including alcohol, ammonia, nicotine, drugs, and harmful by-products of digestion. Old red blood cells are removed from the blood by the liver and spleen, and the iron is cycled to the bone marrow to make new ones. Damage to the liver can impair these and many other processes. Hepatitis is a disorder in which viruses or other mechanisms produce inflammation in liver cells, resulting in their injury or destruction. In most cases this inflammatory process is triggered when the immune system fights off infections caused by viruses. It can also be caused, however, by an overactive immune system that attacks its own liver cells. Inflammation of the liver can also occur from medical problems, drugs, alcoholism, chemicals, and environmental toxins. Hepatitis varies in severity from a self-limited condition with total recovery to a life-threatening or life-long disease.
 Experts define hepatitis as short-term (acute hepatitis) or prolonged (chronic hepatitis). In some cases, acute hepatitis develops into a chronic condition, but chronic hepatitis can also occur on its own. Although chronic hepatitis is generally the more serious condition, patients having either condition can experience varying degrees of severity.
 Acute Hepatitis Acute hepatitis can begin suddenly or gradually, but it has a limited course and rarely lasts beyond one or two months. Usually there are only spotty liver cell damage and evidence of immune system activity, but on rare occasions, acute hepatitis can cause severe -- even life-threatening -- liver damage.

Chronic Hepatitis

The chronic forms of hepatitis persist for prolonged periods. Experts usually categorize chronic hepatitis as either (1) chronic persistent or (2) chronic active hepatitis. Chronic persistent hepatitis is usually mild and nonprogressive or slowly progressive, causing limited damage to the liver. Cell injury in such cases is usually limited to the region of portal tracts, which contains vessels that carry blood to the liver from the digestive tract. In some cases, however, more extensive liver damage can occur over long periods of time and progress to chronic active hepatitis.
 Chronic Active Hepatitis
 If damage to the liver is extensive and cell injury occurs beyond the portal tract, chronic active hepatitis can develop. Significant liver damage has usually occurred by this time. Liver cells are destroyed between the portal tract and the central veins in the liver, and progressive cell damage can build a layer of scar tissue over the liver, resulting in the condition known as cirrhosis. In such cases, the entire liver is threatened with malfunction and failure.
 What Causes Hepatitis? Viral Causes of Hepatitis Most cases of hepatitis are caused by viruses that attack the liver; most are named with the letters A through G. It should be noted that the cause of hepatitis is sometimes unexplained, indicating that additional viruses have not yet been discovered.
  Other Viruses Causing Hepatitis or Liver Damage Hepatitis GB has been discovered as a new distinct form, but it is not known yet whether it causes a serious condition. A number of other common viruses, including herpes simplex, can sometimes injure the liver, although they rarely cause severe hepatitis. Cytomegaloviruses are harmless in most people but can injure the livers in infants and people with impaired immune systems, such as those with AIDS.
 Chronic hepatitis may develop when the body's immune system attacks cells in the liver, a condition called autoimmune chronic hepatitis. Autoimmune chronic hepatitis accounts for about 20% of all chronic hepatitis cases. Like other autoimmune disorders, this condition develops because a genetically defective immune system attacks the body's own cells and organs -- in this case, the liver -- after being triggered by an environmental agent, probably a virus. This agent may be a virus; suspects include the measles virus, a hepatitis virus, or the Epstein-Barr virus, which causes mononucleosis. In about 30% of cases, autoimmune hepatitis is associated with autoimmune disorders that attack other parts of the body, but the relationship between these conditions is unclear.
 Hepatitis Caused by Alcohol and Drugs Alcohol Over time, alcohol abuse leads to increased demands for oxygen by the liver and, at the same time, fat accumulates and impairs the liver's ability to absorb oxygen. Cells in the liver become damaged and may die, possibly leading to cirrhosis, a dangerous and life-threatening condition.
 Drugs Because the liver plays such a major role in metabolizing drugs, hundreds of medications can cause reactions that are similar to those of acute viral hepatitis. Symptoms can appear anywhere from two weeks to six months after starting drug treatment. In most cases, they disappear when the drug is withdrawn, but, in rare circumstances, they may progress to serious liver disease. Among the drugs most prominently cited for liver interactions are halothane, isoniazid, methyldopa, phenytoin, valproic acid, and the sulfonamide drugs. Notably, very high doses of acetaminophen (Tylenol) have been known to cause severe liver damage and even death, particularly when used with alcohol.
 Who Gets Hepatitis? Risk Factors for Hepatitis A About one third of the US population has antibodies to hepatitis A, indicating previous infection by the virus. It infects 180,000 Americans every year. Feces-contaminated water and food are the major sources of infection, and infected people can transmit it to others if they do not take strict sanitary precautions. Of the various strains of hepatitis, hepatitis A is the one people are most likely to encounter in the course of international travel. Outbreaks have occurred in day care centers, but a recent study of child care workers found that incidence of hepatitis A and B among this group was actually lower than in the general population. Risk is low if good hygienic precautions are used, particularly when changing babies and handling diapers. The disease has also been transmitted sexually among homosexual men and it often occurs in intravenous drug users.
 Risk Factors for Hepatitis B and D About 350 million people carry hepatitis B worldwide; it is very common in southern Africa, Asia, and the Mediterranean. It is carried through body fluids. In the U.S., there are about 128,000 new cases every year and about 1 to 1.35 million people with chronic hepatitis B. It can infect children and adults; up to 90% of hepatitis B patients are men. Blood screening and vaccinations have significantly reduced the rate of infection, but drug users who share needles are at considerable risk. Hepatitis B may also be transmitted through sexual activity. Pregnant women with hepatitis B can transmit the virus to their babies. Even if they are not infected at birth, unvaccinated children of infected mothers run a 60% risk of developing it before age five. Children are more likely than adults to become chronic carriers. The virus can be passed from cuts, scrapes, and other breaks in the skin. Also at risk are hospital workers exposed to blood products, staff members of institutions for mentally impaired people, prisoners, and emigrants from areas where the disease rate is high. Contaminated medical instruments, including fingerstick devices used for more than one individual, have been known to transmit the virus.
 Hepatitis D occurs only in people with hepatitis B. It is not common in the U.S. except in intravenous drug abusers and people who require multiple transfusions. Those who have the antibody for hepatitis B are immune to further infection from both hepatitis B and D viruses.

 Risk Factors for Hepatitis C
 About 28,000 people acquire hepatitis C every year and as many as 3.9 million Americans are chronic carriers of the virus. Its primary mode of transmission has been through transfusions. Because of blood screening this risk has been dramatically reduced to 1 in 10,000 since 1990. Hepatitis C can exist for decades, however, without symptoms, and nearly 300,000 people who had transfusions before 1990 may have contracted the virus. Experts urge anyone who had transfusions before 1990 be tested, even though treatments for the virus are limited. People who are still at high risk for hepatitis C include intravenous drug users, intranasal cocaine users, people who have had body-piercing, and organ transplant recipients. Transmission of the virus through contaminated medical devices used in invasive procedures, such as colonoscopy, has been reported. Either sexual promiscuity or a long-term sexual relationship with an infected partner appears to increase the risk. The risk in long-term relationships is about 1% per year. The risk increases with frequency of sexual activity and intimate behavior, such as sharing toothbrushes. Although most health care providers are at low risk, the chance of infection in hospital workers who are accidentally stuck with a needle is high, ranging from 4% to 10%. Unless her own infection is severe, a pregnant woman with this virus is unlikely to pass it on to her infant. Even given these risk factors, it is still not known how 40% of patients acquire this form of hepatitis.

Risk Factors for Hepatitis G
 Hepatitis G is detected in between 1.5% and 3.2% of blood donors and is believed to be more common than hepatitis C. From what is known of hepatitis G, its risk factors are probably similar to those of hepatitis C, although incidence among patients with multiple blood transfusions is much lower than with hepatitis C.
 Risk Factors for Autoimmune Chronic Hepatitis
 Autoimmune chronic hepatitis may occur in women between the ages of 20 and 40 who have other diseases of the immune system, including systemic lupus erythematosus, rheumatoid arthritis, Sjoulmgren's syndrome, inflammatory bowel disease, glomerulonephritis, and hemolytic anemia. About 30% of patients are men, however, and in both genders there is often no relationship to another autoimmune disease. In general, no major risk factors have been discovered for this condition.
 What Are the Symptoms of Hepatitis? Symptoms of Acute Viral Hepatitis General Symptoms Symptoms of acute viral hepatitis may begin suddenly or develop gradually. They may be so mild that patients mistake the disease for the flu. Nearly all patients experience some fatigue and often have mild fever. Gastrointestinal problems are very common, including nausea and vomiting and a general feeling of discomfort in the abdomen or sharper pain that may be localized in the upper right quadrant. This pain tends to increase during jerking movements, such as climbing stairs or riding on a bumpy road. GI problems can lead to loss of appetite, weight loss, and dehydration. After about two weeks, dark urine and jaundice -- a yellowish color in the skin and whites of the eyes -- develops in some, but not all, patients. Children tend not to develop jaundice. About half of all hepatitis patients have light colored stools, muscle pain, drowsiness, irritability, and itching -- usually mild. Diarrhea and joint aches occur in about a quarter of patients. The liver may be tender and enlarged and most people have mild anemia. In about 10% of patients, the spleen is enlarged.

 Symptoms of Fulminant Hepatitis
 In very rare cases, within two months of onset, a very serious condition known as fulminant hepatitis develops. Symptoms may include a large swollen abdomen (known as ascites) and a peculiar hand-flapping tremor (called asterixis). These symptoms may be followed by stomach and intestinal bleeding and mental confusion, stupor, or coma caused by brain injury (encephalopathy).
 Symptoms Typical of Acute Hepatitis A
 Symptoms of hepatitis A are usually mild, especially in children. They generally appear between two and six weeks after exposure to the virus. Adult patients are more likely to have fever, jaundice, and itching that can last one to several months.
 Symptoms Typical of Acute Hepatitis B
 Hepatitis B symptoms appear long after the initial infection -- usually four to 24 weeks. Many patients may not even experience symptoms, or they may be mild and flu-like. About 10% to 20% of patients have a fever and rash. Nausea is not common. Hepatitis B patients may experience general aching in the joints, but sometimes the pain can resemble arthritis, affecting specific joints and accompanied by redness and swelling.

 Symptoms Typical of Acute Hepatitis C
 If they appear at all, symptoms develop about a month or two after a person is infected with hepatitis C. These are usually milder than those of hepatitis B. About 75% of patients show no signs of jaundice, and many do not experience any symptoms.

 Symptoms of Chronic Hepatitis
 Symptoms of Chronic Hepatitis B and C. Both hepatitis B and C can progress to chronic hepatitis usually with no early acute symptoms. Symptoms of progressive chronic viral hepatitis may be very subtle and no more than a mild persistence of acute symptoms for six or more months. In fact, chronic hepatitis C can be present for as long as 20 years without presenting any obvious problems. Some patients develop pain in small joints in the body (such as the hand) that may be nearly indistinguishable from symptoms of rheumatoid arthritis, fibromyalgia, or carpal tunnel syndrome. In other patients, chronic hepatitis B or C can lead to long term disability or liver failure before they experience any symptoms at all.

 Symptoms of Chronic Autoimmune Hepatitis
 The symptoms of chronic autoimmune hepatitis range from minimal to severe, including fatigue, jaundice, fever, and weight loss. The liver and spleen are often enlarged. In addition, patients with this condition may experience skin disorders, including palmar erythema (red palms) and spider angioma (a blood-red spot, the size of a pin head, from which tiny blood vessels radiate like spider legs). Itching is not common, however. The abdomen or legs may be swollen due to the accumulation of fluid.

How Serious Is Hepatitis? Prognosis for Acute Viral Hepatitis In most cases of acute viral hepatitis, recovery is complete and the liver returns to normal within two to eight weeks. In a small number of cases of hepatitis B or C, the condition can be prolonged and recovery may not occur for a year. About 5% to 10% of these patients will experience flare-up of symptoms in a milder form before full recovery. A few of these patients may go on to develop chronic hepatitis. In the rare event that fulminant hepatitis develops, the liver fails and gastrointestinal hemorrhage and brain damage (encephalopathy) occur, resulting in mental confusion, or even coma. Without liver transplantation, death occurs in up to 80% of these cases. Pregnant women with acute hepatitis B, C, or E are at higher risk for these complications. Other serious, and also rare, consequences of acute viral hepatitis are aplastic anemia (which can be fatal), hypoglycemia, and polyarteritis -- a serious inflammation of blood vessels. People who have been infected with a hepatitis virus continue to produce antibodies to that specific virus. This means that they cannot be reinfected with the same hepatitis virus again. Unfortunately, they are not protected from other types.

Specific Prognosis for Hepatitis A and E
 Hepatitis A is the least serious hepatitis virus; it never becomes chronic. Fulminant hepatitis is the major concern, but even if this condition develops, it is less dangerous than with other viral types; only one in a thousand patients are at risk for death from this complication. Similarly hepatitis E is acute and not serious, except in pregnant women, when it can be life-threatening.

Specific Prognosis for Hepatitis B and D
 Acute hepatitis B is lethal in only 1% of patients, but even patients with mild symptoms can remain chronically infected with the virus. Between 5% and 15% of hepatitis B patients carry the virus throughout their lives, and about 25% of these carriers progress to chronic hepatitis. People most at risk for carrying the virus are children infected before they are five and newborns, most of whom become carriers. People most at risk for progression to chronic hepatitis are those infected in early childhood and people with damaged immune systems, such as AIDS patients.
 If a patient with hepatitis B becomes co-infected with hepatitis D, the consequences can be very serious. There is an increased risk for fulminant hepatitis, a life-threatening condition. The risk for developing a chronic form of hepatitis D is the same as for hepatitis B alone.

Specific Prognosis for Acute Hepatitis C
 The mortality rate for acute hepatitis C is well below 1%, but people infected with hepatitis C tend to become life-long carriers of the virus. Between 40% and 60% of these patients develop chronic hepatitis within four years. It is currently not possible to predict which patients will develop the chronic form of hepatitis C.
 Prognosis for Chronic Hepatitis Patients with chronic persistent hepatitis who have few, if any, symptoms generally have a favorable outlook, with only a small risk for developing cirrhosis. In chronic active hepatitis, however, liver biopsies often reveal scarring indicative of cirrhosis and damage to the liver cells that bridge the portal and central veins of the liver. Nearly every bodily process is affected by a damaged liver, including digestive, hormonal, and circulatory systems. Without treatment, encephalopathy, stomach and intestinal bleeding, or kidney failure may eventually develop, with life-threatening consequences. The degree of severity in people with hepatitis caused by viruses B and C usually depends on the degree to which the virus can replicate itself. Viruses that replicate quickly usually cause a more severe form of chronic hepatitis.

Prognosis of Chronic Hepatitis B
 The great majority of people with chronic persistent hepatitis B have a good long-term outlook, but between 5% and 10% become carriers of the virus and 5% to 10% eventually develop cirrhosis. The addition of hepatitis D is a particular danger and increases the risk for cirrhosis. Hepatitis B is a primary cause of liver cancer. In Asia about 15% of people who have chronic hepatitis B develop liver cancer, but this high rate is not seen in other parts of the world. (One Italian study which followed a group of hepatitis B patients for 11 years found no development of liver cancer over that period of time.) Vaccinations for hepatitis B is proving to significantly reduce this risk.

Prognosis of Chronic Hepatitis C
 A recent study reported that from the time of diagnosis, the 10-year risk for the patients in the study developing cirrhosis was 29% and for liver cancer was 14%. It should be noted that these patients had had hepatitis for many years before being diagnosed, so these time frames are not based on when a patient first gets hepatitis. One large study has identified people at highest and lowest risk for developing cirrhosis: people who contracted hepatitis after exposure in a hospital setting, blood transfusion, and when the cause is unknown have a 20% to 30% chance for cirrhosis; those who developed hepatitis C from drug abuse, sexual activity, and occupational exposure have a lower risk -- around 10%. Another study found that drinking alcohol also significantly increased the risk. A study reporting a high rate of hepatitis C in diabetics has led some experts to theorize that the virus may have effects on the immune system or pancreas that could cause this disorder in some people.

Prognosis of Chronic Hepatitis G
 Although only recently identified, experts believe that hepatitis G usually has a mild chronic course and the likelihood of liver damage is low.

Prognosis for Autoimmune Hepatitis
 The persistent form is usually benign and causes little trouble, although there is a very small risk that chronic persistent hepatitis can evolve to the active form. A recent study found that the overall outlook for treated patients with autoimmune hepatitis and no indication of hepatitis viruses was very favorable. In this study, the 10-year survival rate was 95% -- similar to the same age-group in the general population. The five-year survival rate for chronic active form of this hepatitis is only 50% if the disease is not treated. (This rate may be higher in people with milder symptoms and less liver damage.) During the early years, patients are most at risk for liver failure and bleeding in the stomach and esophagus. This risk diminishes over time but is replaced by an increase in liver cancer rates and bleeding in the stomach and intestines. The risk for liver cancer is not has high, however, as with chronic viral hepatitis.

How Is Hepatitis Diagnosed? Tests to Diagnose the Presence of Hepatitis In people suspected of having or carrying viral hepatitis, physicians will measure certain substances in the blood. One of the most important factors indicative of hepatitis is bilirubin, a red-yellow pigment that is normally metabolized in the liver and then excreted in the urine. In patients with hepatitis, the liver cannot process bilirubin, and blood levels of this substance rise, sometimes causing jaundice. Physicians will also look for elevated blood levels of enzymes known as aminotransferases, which are released when the liver is damaged. Aminotransferase levels tend to rise before jaundice develops and to drop after it occurs. High levels do not necessarily mean the condition is very severe, but levels below 500 IU/L generally indicate mild disease.

Tests to Determine Causes of Hepatitis

To identify the particular virus causing hepatitis, blood tests called radioimmunoassays are performed. Some of these tests can pin-point hepatitis antigens, which are proteins that are unique to the specific viruses. More commonly, radioimmunoassays identify particular antibodies, which are molecules in the immune system that attack specific antigens. Antibodies may not appear for up to weeks or months after hepatitis develops, so if the tests are performed too early, they may not detect antibodies even if the patient is infected. Antibodies also persist after patients recover, so a positive antibody test can indicate a previous infection but cannot necessarily determine if the infection is active.

Tests for Hepatitis A
 The first antibodies produced to fight the hepatitis A virus are IgM antibodies. They appear early in the course of the disease and usually can be identified using radioimmunoassays as soon as symptoms appear. IgM antibodies disappear during recovery, but IgG antibodies persist, indicating previous infection.

Tests for Hepatitis B and D
 A radioimmunoassay for hepatitis B must be done promptly to identify the antigen, HBsAg, which is found in the blood in early stages but disappears within four months unless the patient becomes a long-term carrier. Antibodies to the antigen appear during convalescence and may be identified then, even if the antigen itself was missed early on. To diagnose hepatitis D using an antibody test, hepatitis B must also have been identified.

Test for Hepatitis C and G
 A number of tests, particularly one known as enzyme-linked immunosorbent assay (ELISA), are available for identifying the antibody to the hepatitis C virus. The antibody for hepatitis C may not show up for three to six months after the onset of the disease, so the absence of the antibody is not necessarily an indication of a healthy liver. If the physician still firmly believes the virus is present, another test, polymerase chain reaction (PCR), may be performed. A PCR is able to make multiple copies of the genetic material (the RNA) of the virus to the point where it is detectable. It is also the only test available to identify hepatitis G but is very expensive (about $200) and not recommended for what seems to be, so far, a mild disorder.

Tests for Chronic Hepatitis
 Blood tests for chronic hepatitis include measurements of aminotransferase levels, bilirubin levels, and detection of blood clotting problems. Immunoassays to detect antibodies to hepatitis viruses are also performed. If a patient experiences symptoms of chronic active hepatitis for six months or more and a virus cannot be identified, then autoimmune hepatitis is usually suspected. To help confirm this condition, test results may show high levels of immune factors called serum globulins or certain antibodies to liver proteins. In some cases, a successful trial of steroid drugs may be the only way to diagnose autoimmune hepatitis. A liver biopsy may be performed for acute viral hepatitis caught in a late stage or for severe cases of chronic hepatitis. Some experts are now recommending biopsies for all chronic hepatitis C patients, regardless of severity, because of the risk for liver damage even in patients without symptoms. A biopsy helps determine treatment possibilities, the extent of damage, and the long-term outlook.

How Is Acute Hepatitis Treated?
 Treatment for Acute Viral Hepatitis For mild cases of acute viral hepatitis, no drug therapy or other treatment is either available or necessary. Hospitalization is needed only for people at high risk for complications, such as pregnant women, elderly people, patients with other serious conditions, or those who have severe nausea and vomiting and need to have fluids administered intravenously. The primary goals for managing acute viral hepatitis are to provide adequate nutrition, to prevent additional damage to the liver, and to prevent transmission to others. No vitamins or special diets have been proven to be particularly beneficial. Eating many small snacks during the day, with larger ones in the morning, may help prevent weight loss while reducing the severity of nausea. Patients might be able to tolerate high-caloric drinks to supplement the regular diet.
  The liver processes many types of medications, so as soon as hepatitis is diagnosed, the patient should stop taking all drugs, including over-the-counter medications, except those a physician specifically prescribes or recommends. In some cases, the physician may prescribe drugs that have minimal impact on the liver to alleviate the symptoms of hepatitis, such as nausea or severe itching. All patients should abstain from alcohol and sexual contact during the acute phase. Moderate drinking (one or two drinks per evening) after recovery is not harmful for most people. Everyone, however, should avoid taking acetaminophen (Tylenol) with alcohol, which carries a risk for liver damage, even in people without hepatitis.
  Although most patients with hepatitis experience fatigue and require more rest than usual, they can be as physically active as they want without affecting recovery. In fact, patients should be encouraged to be as active as they can. Depression is common, particularly in people used to an active life. Patients should be reassured that in the great a majority of hepatitis cases, recovery is complete.
  At the onset of acute hepatitis, periodic visits to the physician for repeat blood tests are necessary, the frequency of which depends on how well the patient feels. If symptoms still occur after three months and laboratory tests still indicate active presence of the virus, the patient should be evaluated every month. If symptoms persist beyond 6 months, a liver biopsy may be required to determine any liver damage.
  Treatment for Fulminant Acute Hepatitis For those who develop fulminant hepatitis and liver failure, treatment is aimed at the affected organs and systems. No medications, including corticosteroids, has any effect against the condition itself. Liver transplantation is currently the only life-saving treatment for fulminant acute hepatitis and has survival rates of up to 60%. Without liver transplantation, the chance of survival is only 20%.
  How Is Chronic Hepatitis Treated? The goals for treating all forms of chronic hepatitis are to relieve symptoms, prevent the development of cirrhosis, reduce viral levels, and improve survival. The medical therapy of chronic viral hepatitis is very different from the treatment of chronic autoimmune hepatitis, so a correct diagnosis is essential

Anti-Inflammatory Drugs and Treatment of Chronic Autoimmune Hepatitis

Patients with autoimmune hepatitis who have mild symptoms and slight inflammation of the liver do not require any treatment except to alleviate symptoms. They should be monitored, however, for any signs of disease progression. Severe autoimmune hepatitis is a life-threatening condition and requires intensive therapy. Because this hepatitis is caused by an overactive immune system attacking the body's own cells, it is most successfully treated with the steroid drugs prednisone and prednisolone. Steroids suppress the immune system and reduce inflammation, producing remission of symptoms in about 80% of patients. Azathioprine (Imuran) is often prescribed along with steroids to help reduce severe side effects caused by using steroids alone. Azathioprine also suppresses the immune system and helps prevent relapse, but the drug will not induce remission by itself. About half of patients relapse within six months, and only about 20% of patients achieve remission (are disease-free) for more than five years. Readministering prednisone therapy after relapse achieves another remission in 80% of patients. In one promising study, patients who continued to use azathioprine after prednisolone was withdrawn had no relapses for at least a year. Unfortunately, long-term use of azathioprine may increase the risk for cancer, although studies indicate that this risk is very low.
  For most patients, steroids reduce symptoms within three months, improve liver function within six months, and restore liver health within two years. Between 10% and 20% of patients continue to deteriorate despite steroid treatment, although higher doses may help some of these people. Treatment usually needs to continue about two years before the disease is in complete remission, but it rarely lasts more than three years. Side effects can be very distressing and sometimes serious; they include weight gain, skin problems, moon-shaped face, high blood pressure, diabetes, cataracts, mental disturbances, infections, and osteoporosis. Usually, steroids are stopped when disease symptoms have disappeared, when blood tests show that aminotransferase levels are less than two times normal, and liver biopsies reveal no active cell damage. Steroid medications must be withdrawn very slowly. Patients who are very elderly or who have advanced cirrhosis are not good candidates for this treatment. It should also be noted that about 85% of people with chronic active autoimmune hepatitis do not have severe symptoms; in these cases, physicians often must weigh the risk for progression to a more serious condition against the long-term adverse effects of steroid treatment. If all therapies fail and the disease becomes life-threatening, liver transplantation may be performed. Because of all of these effective treatment options and in spite the high rate ofrreaapse, long-term survival rates in patients with autoimmune hepatitis are excellent. (Steroids are generally not useful for chronic hepatitis B or C and, in fact, suppressing the immune system in these patients can encourage the viruses to replicate more quickly.)

Drug Treatment for Chronic Hepatitis B, D, or C

Drug treatments for chronic hepatitis B, D and C are aimed at reducing or preventing liver damage and boosting or modifying the immune system to promote its attack on the viruses. Treatment outcomes are assessed by testing levels of aminotransferase to determine liver damage and using polymerase chain reaction (PCR) tests to detect the amount of virus left. After treatment, however, some patients may have low levels of virus and high indicators of liver damage while others display opposite results. It is not yet clear how to weigh these criteria in evaluating the overall health of the patient.

Interferons

Interferons act directly against the virus. The standard drug currently used for chronic viral hepatitis B, D, and C is interferon alpha-2b (Roferon-A, Intron A). Other interferons are being tested, including recombinant type-I interferon (Infergen) and interferon beta, which is benefiting many children with hepatitis B who do not respond to interferon-alpha. In those who respond to interferon, studies are showing improved symptoms, a normal long-term survival rate, and, in some, no return of the disease. The percentage of patients who benefit over the long-term, however, is small. Not all patients are candidates; among others, the treatment is inappropriate for patients with advanced hepatitis, fluid in the abdomen, or any serious medical or psychiatric problems. Even when the drug is effective, the disease recurs half the time and requires additional treatment.
  Patients with hepatitis B should be given interferon if they show signs of liver damage; it is not recommended for those with normal aminotransferase levels. The drug has eliminated the virus and sustained significant remission in 25% to 40% of patients with chronic hepatitis B. The drug is usually taken by injection every day for 16 weeks.
  In patients with hepatitis C taking interferon for six months there is an even lower average rate of sustained response -- about 15%. (Although studies indicate this rate can be boosted to 24% with treatment of a year or longer.) Early eradication of the virus is the most important factor for success In one study, over 75% of patients whose viral count was eliminated in the first week had a sustained response. However, only 35% of those whose count was down by week two and 12.5% of those whose count was down by the fourth week had a sustained response. In some cases, a very short course of corticosteroids may be used initially to boost the effect of interferon. (In such cases, the steroids do no harm.) Effects of the drug may be enhanced before treatment in certain patients by reducing iron levels through a series of blood-drawings. Combinations with other drugs, including ribavirin, thymosin alpha, or ursodeoxycholic acid, are showing promise (for more information on these drugs, see discussions below).
  Common side effects are flu-like symptoms that usually occur within six hours and last for 12. More chronic effects include depression, irritability, weight loss, vomiting, and general weakness. Interferon often causes a drop in platelet and white blood cell counts, increasing susceptibility to bacterial infections. It may also trigger an autoimmune response, possibly causing anemia, diabetes, lupus-like symptoms, thyroid abnormalities, or even autoimmune hepatitis.

Nucleoside Analogues

Among the drugs showing promise for patients who do not respond to interferon are nucleoside analogues, which directly affect viral replication. Such drugs include ribavirin, lamivudine (Epivir), famciclovir (Famvir), and adefovir. Lamivudine has reduced hepatitis B to undetectable levels after four weeks. Unfortunately, the virus recurs in almost all cases, although this recurring mutation may be weaker than the original strain. Administering the drug for longer periods may produce sustained remission in more patients while still being safe. A study using adefovir, also called GS840, reported a drop in hepatitis B virus levels of 97% in 20 patients. For hepatitis C patients, the most promising treatment is a combination of ribavirin and interferon alpha (Rebetol), which has produced sustained improvement in 40% to 77% of hepatitis C patients. This treatment may not be effective, however, in people with severe or late-stage disease.
  Other Drugs that Stimulate the Immune System Immunomodulators are drugs that modify or regulate part of the immune system. One of these, thymosin is a synthetic version of a peptide derived from the thymus gland and is a promising therapy when used alone or in combination with interferon for hepatitis B or when used in combination with interferon for hepatitis C. Vaccines, including Hepagene, are being investigated for treating and preventing hepatitis B.

Other Investigative Drugs

Amantadine (Symmetrel) is a drug commonly used for Parkinson's disease but which may have some antiviral effects. In hepatitis C patients who had failed interferon, the drug produced normal aminotransferase levels in 27% and it reduced the viral load to undetectable levels while producing a sustained response in 18% of these patients. Ursodiol, or ursodeoxycholic acid, a drug ordinarily used for gallstones, improves aminotransferase levels, although it has no effect against the virus. For hepatitis C patients it may prove useful in combination with interferon but it is not useful alone.
  Liver Transplantation If treatment fails for any type of severe hepatitis, liver transplantation may be tried, although hepatitis B patients have a success rate of only 50% to 60% because of recurrence. (The success rate is higher in those who have hepatitis D.) Experiments using monthly infusions of hepatitis B immune globulin (HBIg) after transplantation show great promise in preventing recurrence in these patients. This may need to be administered life long. One study reported that lamivudine may be helpful in preventing recurrence of hepatitis B after liver transplantation. Hepatitis C also commonly returns in transplanted livers, progressing to cirrhosis within an average of 51 months in 8% of patients. Autoimmune hepatitis may also recur after liver transplantation, but only after several years. Unfortunately, there are only about half the number of available livers as there are candidates. New regulations controlling liver transplantation now give priority to patients with the best chance of long-term survival -- such as a young person with severe mushroom poisoning as opposed to an elderly person with alcoholic cirrhosis.

  How Is Transmission of Hepatitis Prevented?
  Periods of Highest Contagion Hepatitis A is infectious for two to four weeks before symptoms develop and for a few days afterward. People with hepatitis B or C may become carriers of the virus after recovery, even if chronic disease does not develop and symptoms are not present.
  Life-Style Preventive Measures
  Daily Precautions Patients with viral hepatitis should abstain from sexual activity or take strict precautions if they cannot. Sterilizing utensils or clothing is not necessary with any type of hepatitis, but hot water and thorough cleanings are necessary for items used by patients with hepatitis E and A. Utensils used by the patient for eating and cooking should be kept separate from those used by others. Because hepatitis A and E are usually passed through contaminated food, people with these viruses should not prepare food for others; unfortunately these viruses are most contagious before symptoms appear. Restrictions on food preparation are not necessary for other types of hepatitis. All objects contaminated by blood from patients with hepatitis B or C must be handled with special care.
  Travel to Countries at High Risk for Hepatitis Travelers should be vaccinated against hepatitis A if they are traveling for long periods of time to countries where epidemics occur. They should peel and wash all fresh fruits and vegetables themselves and avoid raw or undercooked meat and fish. Even ice cubes can cause infection, and only carbonated bottled water should be used for brushing teeth and drinking. If carbonated water is not available, tap water should be boiled for ten minutes.
  Vaccinations and Preventive Measures for Specific Viruses Prevention of Hepatitis A
  The standard preventive measure against hepatitis A has been immune globulin (formerly gamma globulin) injections. A vaccine, Havrix, is now available and is very safe and effective. It can be given along with immune globulin and other vaccines. Although not yet routinely given to children under two, the vaccine is proving to be safe for infants. People who should receive Havrix include those in communities where outbreaks occur, sexually active homosexual men, people with chronic liver disease, health care workers exposed to the virus, and travelers to developing countries. Travelers should also receive immune globulin if they are visiting high risk areas within four weeks of the vaccination. There are few side effects although allergic responses can occur. Hair loss has been reported in a very few people after a second administration.

Prevention of Hepatitis B and D

All transfused blood is now tested for both hepatitis B and C, significantly reducing the risk from this source. Several vaccines, including Recombivax HB, GenHevac B, Hepagene, and Engerix-B, can prevent hepatitis B and are effective and safe, including for infants and children. Vaccination programs are also proving to reduce the risk for liver cancer. Because the incidence of hepatitis B is rising in the U.S., experts recommend immunization against hepatitis B in all infants and children older than eleven and those under eleven who live in areas populated by immigrants from countries with a high incidence of the disease. Others who should be vaccinated are people who have had sexual contact with infected individuals, health care workers who may come in contact with contaminated blood or body fluids, and people who travel frequently or stay for prolonged periods in countries with high prevalence of this disease. Three doses given over six months are usually required for adults; a recent study reported that older adults would benefit from a fourth dose without incurring serious side effects. People with alcoholism, who often have a lower response, may be protected with high doses. A small percentage of people do not develop immunity even after a vaccine has been given repeatedly. A more potent vaccine is proving to be effective in many people who do not respond to a standard vaccine. The vaccine loses its effect after five years in about a third of those who had it, but the value of a booster shot is uncertain. Preventing hepatitis B also prevents hepatitis D. Screening pregnant women for hepatitis B and then treating the infants of infected mothers as soon as they are born appear to be very effective prevention strategies for newborns. Treatment is with immune globulin and a series of vaccinations at birth, one month, and six months.

Prevention of Hepatitis C

Although transfused blood has been tested for both hepatitis B and C since 1990, those with previous transfusions -- even those performed decades ago -- may be at risk. Such individuals are urged to be tested. Immune globulin helps protect against developing hepatitis C after transfusions. Periodic doses of immune globulin in sexual partners of infected people also appear to confer protection. Avoiding exposure or preventing transmission is, however, still very important for hepatitis carriers and for those in contact with them. Infected patients should use condoms and contraceptives that prevent passage of the virus, possibly even in relationships that last for years. Sexual partners, no matter what the duration of the relationship, should avoid sharing personal items, such as razors or toothbrushes, and abstain from sexual activity during menstruation or infections that cause bleeding in the genital or urinary areas. Community needle exchange programs should be encouraged. Studies are finding that these programs reduce the incidence of both hepatitis and AIDS significantly without encouraging drug abuse.


\2 some more on Hepatitis A

Some exotic spots can posecertain health risks. One of those risks, hepatitis A, is particularly dangerous. Travel to Asia, Africa, the Caribbean, the Mediterranean, Eastern Europe, Latin America, and the Middle East can put you at risk for hepatitis A.
 As many as 22% of adults who contract hepatitis A are hospitalized. Some cases are fatal. But, there is a vaccine.

CDC recommends a hep-A vaccine before traveling to at-risk areas.
 - A a liver disease caused by the hep-A virus. It can affect anyone. In the US, hep-A can occur in situations ranging from isolated cases to widespread epidemics.
 Good personal hygiene and proper sanitation can help prevent hepatitis A. Vaccines are also available for long-term prevention of hepatitis.


Hepatitis A is transmitted by contaminated food and drinking water. The disease poses a real threat to the western traveller. You should seek medical advice, but there is not much you can do apart from resting, drinking lots of fluids, eating lightly and avoiding fatty foods. People who have had hepatitis should avoid alcohol for some time after the illness, as the liver needs time to recover.

 Hepatitis A Virus
 1. Name of the Organism: Hepatitis A VirusHepatitis A virus (HAV) is classified with the
 enterovirus group of the Picornaviridae family. HAV has a single molecule of RNA surrounded by a small (27 nm diameter) protein capsid and a buoyant density in CsCl of 1.33 g/ml. Many other picornaviruses cause human disease, including polioviruses, coxsackieviruses, echoviruses, and rhinoviruses (cold viruses).
  2. Name of Acute Disease:The term hepatitis A (HA) or type A viral hepatitis has replaced all previous designations: infectious hepatitis, epidemic hepatitis, epidemic jaundice, catarrhal jaundice, infectious icterus, Botkins disease, and MS-1 hepatitis.
 
 3. Nature of Disease:Hepatitis A is usually a mild illness characterized by sudden onset of fever, malaise, nausea, anorexia, and abdominal discomfort, followed in several days by jaundice. The infectious dose is unknown but presumably is 10-100 virus particles.
  4. Diagnosis of Human Illness:Hepatitis A is diagnosed by finding IgM-class anti-HAV in serum collected during the acute or early convalescent phase of disease. Commercial kits are available.
  5. Associated Foods:HAV is excreted in feces of infected people and can produce clinical disease when susceptible individuals consume contaminated water or foods. Cold cuts and sandwiches, fruits and fruit juices, milk and milk products, vegetables, salads, shellfish, and iced drinks are commonly implicated in outbreaks. Water, shellfish, and salads are the most frequent sources. Contamination of foods by infected workers in food processing plants and restaurants is common.
  6. Frequency of Disease:Hepatitis A has a worldwide distribution occurring in both epidemic and sporadic fashions. About 22,700 cases of hepatitis A representing 38% of all hepatitis cases (5-year average from all routes of transmission) are reported annually in the U.S. In 1988 an estimated 7.3% cases were foodborne or waterborne. HAV is primarilly transmitted by person-to-person contact through fecal contamination, but common-source epidemics from contaminated food and water also occur. Poor sanitation and crowding facilitate transmission. Outbreaks of HA are common in institutions, crowded house projects, and prisons and in military forces
 in adverse situations. In developing countries, the incidence of disease in adults is relatively low because of exposure to the virus in childhood.
  Most individuals 18 and older demonstrate an immunity that provides lifelong protection against reinfection. In the U.S., the percentage of adults with immunity increases with age (10% for those 18-19 years of age to 65% for those over 50). The increased number of susceptible individuals
 allows common source epidemics to evolve rapidly.
  7. Usual Course of Disease:The incubation period for hepatitis A, which varies from 10 to 50 days (mean 30 days), is dependent upon the number of
 infectious particles consumed. Infection with very few particles results in longer incubation periods. The period of communicability extends from early in the incubation period to about a week after the development of jaundice. The greatest danger of spreading the disease to others occurs during the middle of the incubation period, well before the first presentation of symptoms. Many infections with HAV do not result in
 clinical disease, especially in children. When disease does occur, it is usually mild and recovery is complete in 1-2 weeks. Occasionaly, the symptoms are severe and convalescence can take several months. Patients suffer from feeling chronically tired during convalescence, and their inability to work can cause financial loss. Less than 0.4% of the reported cases in the U.S. are fatal. These rare deaths usually occur in the elderly.
  8. Target Population:All people who ingest the virus and are immunologically unprotected are susceptible to infection. Disease however, is more common in adults than in children.
  9. Analysis of Foods:The virus has not been isolated from any food associated with an outbreak. Because of the long incubation period, the
 suspected food is often no longer available for analysis. No satisfactory method is presently available for routine analysis of food, but sensitive molecular methods used to detect HAV in water and clinical specimens, should prove useful to detect virus in foods. Among those, the PCR amplification method seems particularly promising.
  10. Selected Outbreaks:Hepatitis A is endemic throughout much of the
 world. Major national epidemics occurred in 1954, 1961 and 1971. Although no major epidemic occurred in the 1980s, the incidence of hepatitis A in the U.S. increased 58% from 1983 to 1989. Foods have been implicated in over 30 outbreaks since 1983. The most recent ones and the suspected contaminated foods include:
 1987 - Louisville, Kentucky. Suspected source: imported lettuce.
 1988 - Alaska. Ice-slush beverage prepared in a local market. - North
 Carolina. Iced tea prepared in a restaurant. - Florida. Raw oysters
 harvested from nonapproved bed.
 1989 - Washington. Unidentified food in a restaurant chain.
 1990 - North Georgia. Frozen strawberries. - Montana. Frozen
 strawberries. - Baltimore. Shellfish.
 -- formerly called infectious hepatitis, is always acute and never becomes chronic. The virus is excreted in feces and transmitted in contaminated food and water. Eating shellfish taken from sewage-contaminated water is a common means of contracting hepatitis A. It can also be acquired by close contact with individuals infected with the virus. The hepatitis A virus does not directly kill liver cells, and experts do not yet know how the virus actually injures the liver.

Hepatitis A is transmitted by contaminated food and drinking water. The disease poses a real threat to the western traveller. You should seek medical advice, but there is not much you can do apart from resting, drinking lots of fluids, eating lightly and avoiding fatty foods. People who have had hepatitis should avoid alcohol for some time after the illness, as the liver needs time to recover. 

Viral Hep-A: FAQ By The CDC. 

What Is Hep-A? Hep-A is a liver disease caused by hep-A virus.

What Are the Signs and Symptoms of Hepatitis A?

Persons with hep-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, tired- ness, loss of appetite, nausea, abdominal discomfort, dark urine, and jaundice (yellowing of the skin and eyes). Symptoms usually last less than 2 mths; a few persons are ill for as long as 6 mths. The aver incuba- tion period for hep-A is 28 days (range: 15-50 days).

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

How Is Hepatitis A Virus Transmitted? Hep-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 hep-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.

What Products Are Available to Prevent Hepatitis A Virus Infection? Two products are used to prevent hep-A virus infection: immune globulin and hep-A vaccine.

1. 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.

2. Hepatitis A vaccine has been licensed in the US for use in persons 2 years of age and older. The vaccine is recommended (before exposure to hep-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 hep-A. The vaccines currently licensed in the US are HAVRIX? (manf by SmithKline Beecham Biologicals) and VAQTA? (manf by Merck & Co., Inc).

How Are Hepatitis A Vaccines Made? There is no live virus in hep-A vaccines. The virus is inactivated during produ- ction of the vaccines, similar to Salk-type inactivated polio vaccine.

Is Hepatitis A Vaccine Safe? Yes, hep-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.

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.

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.

Is Immune Globulin in Short Supply (2001)? Yes. This shortage is expected to continue necessitating a prior- itization of indications for the use of immune globulin.

Can Other Vaccines Be Given at the Same Time That Hep-A Vaccine Is Given?Yes. Hep-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 hep-A vaccine is given, but at a diff injection site.

How Long Does Immunity Last after Hep-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.

When Are Persons Protected after Receiving Hepatitis A Vaccine?

Protection against hepatitis A begins four weeks after the first dose of hepatitis A vaccine. Check with your doctor for when the next dose is due.

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.

Should Prevaccination Testing Be Done?

Prevaccination 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.

Should Postvaccination Testing Be Done?

No.

We gave our patients the first dose of a 3-dose series of HAVRIX (360 EL.U.) to protect them from hepatitis A. Can we just give one additional dose of 720 EL.U. to complete the vaccination series?

There are no studies that have looked at this issue. It is recommended that these children complete the 3-dose series with the 360 EL.U. formulation. If this formulation is not available to complete the vaccination series, a single dose of the 720 EL.U. formulation should provide more than adequate protection.

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.

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.

Can Hepatitis A Vaccine Be Given during Pregnancy or Lactation? 

We don? 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.

Can Hepatitis A Vaccine Be Given to Immunocompromised Persons? (e.g., Persons on Hemodialysis or Persons with AIDS)

Yes.

Persons Who Should Receive Hepatitis A Vaccine

Hepatitis A vaccination provides protection before one is exposed to hepatitis A virus. Hepatitis A vaccination is recommended for the following groups who are at increased risk for infection and for any person wishing to obtain immunity.

Persons Traveling to or Working in Countries That Have High or Intermediate Rates of Hepatitis A.

All susceptible persons traveling to or working in countries that have high or intermediate rates of hepatitis A should be vaccinated or receive immune globulin before traveling. Persons from developed countries who travel to developing countries are at high risk for hepatitis A. Such persons include tourists, military personnel, missionaries, and others who work or study abroad in countries that have high or intermediate levels of of hepatitis A. The risk for hepatitis A exists even for travelers to urban areas, those who stay in luxury hotels, and those who report that they have good hygiene and that they are careful about what they drink and eat.

Children in Communities That Have High Rates of Hepatitis A and Periodic Hepatitis A Outbreaks.

Children living in communities that have high rates of hepatitis A (e.g., American Indian, Alaska Native) should be routinely vaccinated beginning at 2 years of age. High rates of hepatitis A are generally found in these populations, both in urban and rural settings. In addition, to effectively prevent epidemics of hepatitis A in these communities, vaccination of previously unvaccinated older children is recommended within 5 years of initiation of routine childhood vaccination programs. Although rates differ among areas, available data indicate that a reasonable cutoff age in many areas is 10-15 years of age because older persons have often already had hepatitis A. Vaccination of children before they enter school should receive highest priority, followed by vaccination of older children who have not been vaccinated.

Men Who Have Sex with Men

Sexually active men (both adolescents and adults) who have sex with men should be vaccinated.

Hepatitis A outbreaks among men who have sex with men have been reported frequently. Recent outbreaks have occurred in urban areas in the United States, Canada, and Australia.

Illegal-Drug Users

Vaccination is recommended for injecting and noninjecting illegal-drug users if local health authorities have noted current or past outbreaks among such persons.

During the past decade, outbreaks have been reported among injecting-drug users in the United States and in Europe.

Persons Who Have Occupational Risk for Infection

Persons who work with hepatitis A virus-infected primates or with hepatitis A virus in a research laboratory setting should be vaccinated. No other groups have been shown to be at increased risk for hepatitis A virus infection because of occupational exposure.

Outbreaks of hepatitis A have been reported among persons working with non-human primates that are susceptible to hepatitis A virus infection, including several Old World and New World species. Primates that were infected were those that had been born in the wild, not those that had been born and raised in captivity.

Persons Who Have Chronic Liver Disease

Persons with chronic liver disease who have never had hepatitis A should be vaccinated, as there is a higher rate of fulminant (rapid onset of liver failure, often leading to death) hepatitis A among persons with chronic liver disease. Persons who are either awaiting or have received liver transplants also should be vaccinated.

Persons Who Have Clotting-Factor Disorders

Persons who have never had hepatitis A and who are administered clotting-factor concentrates, especially solvent detergent-treated preparations, should be given hepatitis A vaccine.

All persons with hemophilia (Factor VIII, Factor IX) who receive replacement therapy should be vaccinated because there appears to be an increased risk of transmission from clotting-factor concentrates that are not heat inactivated.

Groups for Whom Hepatitis A Vaccine Is Not Routinely Recommended

Food Service Workers

Foodborne hepatitis A outbreaks are relatively uncommon in the United States; however, when they occur, intensive public health efforts are required for their control.

Although persons who work as food handlers have a critical role in common-source foodborne outbreaks, they are not at increased risk for hepatitis A because of their occupation. Consideration may be given to vaccination of employees who work in areas where community-wide outbreaks are occurring and where state and local health authorities or private employers determine that such vaccination is cost-effective.

Sewerage Workers

In the United States, no work-related outbreaks of hepatitis A have been reported among workers exposed to sewage.

Health-Care Workers

Health-care workers are not at increased risk for hepatitis A. If a patient with hepatitis A is admitted to the hospital, routine infection control precautions will prevent transmission to hospital staff.

Children Under 2 Years of Age

Because of the limited experience with hepatitis A vaccination among children under 2 years of age, the vaccine is not currently licensed for this age-group.

Day-Care Attendees

The frequency of outbreaks of hepatitis A is not high enough in this setting to warrant routine hepatitis A vaccination. In some communities, however, day-care centers play a role in sustaining community-wide outbreaks. In this situation, consideration should be given to adding hepatitis A vaccine to the prevention plan for children and staff in the involved center(s).

Travel and the Prevention of Hepatitis A

Anti-HAV Prevalence

Who Should Receive Protection Against Hepatitis A Before Travel?

All susceptible persons traveling to or working in countries that have high or intermediate rates of hepatitis A should be vaccinated or receive immune globulin before traveling. Persons from developed countries who travel to developing countries are at high risk for hepatitis A. Such persons include tourists, military personnel, missionaries, and others who work or study abroad in countries that have high or intermediate levels of of hepatitis A. The risk for hepatitis A exists even for travelers to urban areas, those who stay in luxury hotels, and those who report that they have good hygiene and that they are careful about what they drink and eat.

How Soon Before Travel Should the First Dose of Hepatitis A Vaccine Be Given?

Protection against hepatitis A virus infection begins four weeks before travel. Check with your doctor about when the next dose is due.

What Should Be Done If a Person Cannot Receive Hepatitis A Vaccine?

Travelers who are allergic to a vaccine component or who elect not to receive vaccine should receive a single dose of immune globulin (0.02 mL/kg), which provides effective protection against hepatitis A for up to 3 months. Travelers whose travel period exceeds 2 months should be administered immune globulin at 0.06 mL/kg; administration must be repeated if the travel period exceeds 5 months. Note!! Immune globulin is in very short supply and the supply is often not adequate for use in this setting.

If Travel Starts Sooner Than 4 Weeks Prior to the First Vaccine Dose, What Should Be Done?

Because protection may not be complete until 4 weeks after vaccination, persons traveling to a high-risk area less than 4 weeks after the initial dose of hepatitis A vaccine should also be given immune globulin (0.02 mL/kg), but at a different injection site. Note!! Immune globulin is in very short supply and the supply is often not adequate for use in this setting. Therefore, the first dose of hepatitis A vaccine should be administered as soon as travel to a high-risk area is planned.

What Should Be Done for Travelers Who Are Less Than 2 Years of Age to Protect Them from Hepatitis A Virus Infection?

Immune globulin is recommended for travelers less than 2 years of age because the vaccine is currently not licensed for use in this age group. Note!! Immune globulin is in very short supply and the supply is often not adequate for use in this setting.

Source: MMWR; Prevention of Hepatitis A Through Active or Passive Immunization

The Centers for Disease Control and Prevention. CDC Fact Sheet: Viral Hepatitis A: Frequently Asked Questions. February 02, 2000. (Online)http://www.cdc.gov/ncidod/diseases/hepatitis/a/ faqa.htm 


\3 some more on Hepatitis B and D

The virus for hepatitis B, formerly called serum hepatitis, is found in semen, blood, and saliva. It is usually spread by blood transfusions, contaminated needles, and sexual contact. Blood screening as reduced the risk from transfusions. The virus does not kill cells directly, but seems to activate cells in the immune system, which cause inflammation and damage in the liver.

Hepatitis D virus can replicate only by attaching to hepatitis B and therefore cannot exist without the B virus being present. Between 1% and 10% of hepatitis B patients go on to develop chronic hepatitis and hepatitis B can become chronic without an acute stage.

Viral Hepatitis B - FAQ Who is at risk? Hep-B can affect anyone. Each year in the United States, more than 200,000 people of all ages get hepatitis B and close to 5,000 die of sickness caused by HBV. If you have had other forms of hepatitis, you can still get hep-B. 

Get vaccinated! Hepatitis B is preventable. How great is your risk for hepatitis B?

One out of 20 people in the US 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, live in the same house with someone who has lifelong HBV infection, have a job that involves contact with human blood, shoot drugs, are a patient or work in a home for the developmentally disabled, have hemophilia, travel to areas where hep-B is common,Your risk is also higher if your parents were born in SE Asia, Africa, the Amazon Basin in South America, the Pacific Islands, and the Middle East. 

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

All babies, beginning at birth, should get hepatitis B vaccine. 

How do you get hep-B? You get hepatitis B by direct contact with the blood or body fluids of an infected person; for example, you can become infected by having sex or sharing needles with an infected person. A baby can get hep-B from an infected mother during childbirth. 

Hep-B is not spread through food or water or by casual contact. 

Who is a carrier of hep-B virus? 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. 

How do you know if you have hep-B? You may have hep-B (and be spreading the disease) and not know it; sometimes a person with HBV infection has no symptoms at all. 

If you have symptoms, your eyes or skin may turn yellow. You may lose your appetite. You may have nausea, vomit- ing, fever, stomach or joint pain. you may feel extremely tired and not be able to work for weeks or months 

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

If vaccine was never given, children 0-18 years of age should get hepatitis B vaccine. 

If you are pregnant, should you worry about hepatitis B? 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. 

Who should get vaccinated? All babies, at birth All children 0-18 years of age who have not been vaccinated Persons of any age whose behavior puts them at high risk for HBV infection Persons whose jobs expose them to human blood 

-- Hepatitis B Vaccine What is hepatitis B? How is hepatitis B vaccine used to prevent hepatitis B and its related complications? For whom is hepatitis B vaccine recommended? Why not vaccinate children in those families where there is the highest risk of HBV infection, rather than vaccinating all infants/children? Is hepatitis B vaccine safe? Is there an association between hepatitis B vaccine and serious side effects? Does hepatitis B vaccination cause demyelinating diseases such as multiple sclerosis (MS)? How is vaccine safety monitored after it is licensed for use? 

Where can I find more info about Hep-B and HBV? 

 What is hepatitis B? 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. 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. 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).

How is hep-B vaccine used to prevent hepatitis B and its related complications? Hep-B vaccine prevents both HBV infection and those diseases related to HBV infection. It has been available since 1982. Hepatitis B vaccines currently available in the United States are made using recombinant DNA technology, and contain only a portion of the outer protein of HBV or hepatitis B surface antigen [HBsAg] (Emini, 1986; Stephenne, 1990). The vaccine does not contain any live components. 

The vaccine is given as a series of three intramuscular doses. More than 95% of children and adolescents, and more than 90% of young, healthy adults develop adequate antibody to the recommended series of three doses (Szmuness, 1980; Zajac, 1986; Andre, 1989). Persons who respond to hepatitis B vaccine are protected against acute hep-B as well as the chronic consequences of HBV infection, including cirrhosis and liver cancer (CDC, 1991 a; Hadler, 1992).

For whom is hepatitis B vaccine recommended? The Advisory Committee on Immunization Practices (ACIP) recommends hepatitis B vaccine for everyone 18 years of age and younger, and for adults over 18 years of age who are at risk for HBV infection (CDC, 1991 a,b; 1996). Hepatitis B vaccine has been recommended as a routine infant vaccination since 1991, and as a routine adolescent vaccination since 1995 (CDC, 1991,CDC 1996). 

Adults who are at increased risk of HBV infection and who should receive the vaccine include: sexually active heterosexual adults with more than one sex partner in the prior 6 months or a history of a sexually transmitted disease; men who have sex with men; illicit injection drug users, persons at occupational risk of infection; hemodialysis patients; and household and sex contacts of persons with chronic HBV infection; clients and staff of institutions for the developmentally disabled; (CDC, 1991 b). click here for risk groups for whom vaccine is recommended

Why not vaccinate children in those families where there is the highest risk of HBV infection, rather than vaccinating all infants/children?

Routine immunization of infants and adolescents is recommended for several reasons. One is that there is a large disease burden attributable to HBV infections that occur among children. Approx 30,000 infants and children were infected each year before routine infant hep-B immunization began and CDC estimates that one-third of the chronic HBV infections in the US come from infected infants and young children. The majority of these infections occur among children of mothers who are not infected with HBV and thus would not be prevented by perinatal hep-B prevention pgms. Other than for infants born to HBV infected pregnant women, there is no way to identify and selectively vaccinate those children at risk of infection. (Margolis, 1991).

Another reason we vaccinate infants and older children is that it will provide them protection against exposure to HBV infection when they are older adolescents and adults. While most HBV infections occur among older adolescents and young adults, vaccination of persons in high risk groups has generally not been a successful public health strategy. In addition, about 30% of persons do not know where they acquired their acute HBV infection (Alter, 90)

Is hepatitis B vaccine safe? Hepatitis B vaccines have been shown to be very safe when given to infants, children or adults (CDC, 1991 a; Greenberg, 1993). More than 20 million persons have received hep-B vaccine in the US and more than 500 million persons have received the vaccine worldwide. The most common side effects from hepatitis B vaccination are pain at the injection site and mild to moderate fever.

Studies show that these side effects are reported no more frequently among those vaccinated than among persons not receiving vaccine (Szmuness, 1980; Francis, 1982). Among children receiving both hep-B vaccine and diphtheria- tetanus-pertussis (DTP) vaccine, these mild side effects have been observed no more frequently than among children receiving DTP vaccine alone (CDC, 1991 a; Greenberg, 93).

Is there an assoc between hep-B vaccine and serious side effects?

Serious side effects reported after receiving hepatitis B vaccine are very uncommon (Andre, 1989; CDC, 1991 a; Greenberg, 1993). There is no confirmed scientific evidence that hepatitis B vaccine causes chronic illness, including multiple sclerosis, chronic fatigue syndrome, rheumatoid arthritis, or autoimmune disorders. There is no risk of HBV infection from the vaccine.

Large-scale hepatitis B immunization programs in Taiwan, Alaska, and New Zealand have observed no association between vaccination and the occurrence of serious adverse events. Furthermore, surveillance of adverse events in the United States after hepatitis B vaccination have shown no association between hepatitis B vaccine and the occurrence of serious adverse events including Guillain-Barre' syndrome, transverse myelitis, optic neuritis, and seizures (Shaw, 1988; CDC, 1991 a; Chen, 1991; Niu, 1996; Niu 1998 CDC, unpublished data).

A low rate of anaphylaxis (hives, difficulty breathing, shock) has been observed in vaccine recipients based on reports to the Vaccine Adverse Event Reporting System (VAERS), with an estimated incidence of 1 in 600,000 vaccine doses distributed. One case has been reported in 100,763 children (10-11 years old) vaccinated with recombinant vaccine in British Columbia and no cases were observed in 166,757 children vaccinated in New Zealand. 

Although none of the persons who developed anaphylaxis died, anaphylactic reactions can be life-threatening, and therefore further vaccination with hepatitis B vaccine is contraindicated in persons with a history of anaphylaxis after a previous dose of vaccine. There have been rare reports of hair loss after hepatitis B vaccination, with the majority of individuals regrowing their hair (Wise, 1997). Studies are in progress to better quantify the possible slight risk of hair loss.

Any presumed risk of adverse events associated with hepatitis B vaccination must be balanced with the expected 4,000 to 5,000 HBV-related liver disease deaths that would occur without immunization, assuming a 5% lifetime risk of HBV infection.

 Does hepatitis B vaccination cause demyelinating diseases such as multiple sclerosis (MS)? The scientific evidence to date does not support hepatitis B vaccination causing multiple sclerosis (MS) or other demyelinating diseases.

Multiple sclerosis is a disease of the central nervous system characterized by the destruction of the myelin sheath surrounding neurons, resulting in the formation of "plaques". MS is a progressive and usually fluctuating disease with exacerbations (patients feeling worse) and remissions (patients feeling better) over many decades. Eventually, in most patients, remissions do not reach baseline levels and permanent disability and sometimes death occurs. The cause of MS is unknown. The most widely held hypothesis is that MS occurs in patients with a genetic susceptibility and that some environmental factors "trigger" exacerbations. MS is 3 times more common in women than men, with diagnosis usually made as young adults.

The concern that hepatitis B vaccination may cause MS or exacerbate it derives from case reports and media attention in France and, more recently, televised news reports in the United States. However, it is possible that these MS case reports are purely coincidental to hepatitis B vaccination. Carefully controlled studies (currently underway) are needed to determine the nature of these reports.

Other than these case reports, what then is the current scientific evidence that hepatitis B vaccination causes MS or other demyelinating diseases? First, extensive pre-licensure clinical trials did not document such an effect. Second, hundreds of millions of persons worldwide have been immunized without developing MS (or any other autoimmune disease). This finding provides important negative evidence as well as an appropriate framework for assessing this possible association-namely, that if vaccination causes MS, it does so extremely rarely.

Third, prospective studies of MS patients have shown that exacerbations appeared to be more frequent after nonspecific viral illnesses (Sibley, 1985). This is presumably due to generalized stimulation of the immune system that occurs with such infections (Owen, 1980). 

Given the intent of immunizations is to stimulate the immune system, it is not surprising therefore that exacerbations of MS have been reported after various vaccinations (Poser, 1994). Given the large number of vaccinations administered worldwide, it is also not surprising that surveillance systems in the U.S., France, and elsewhere (Quast, 1991), have received some reports of MS temporally (coincidentally) associated with vaccinations. As with all such case reports, however, they only constitute signals of possible causal associations. Further controlled studies are necessary to establish causation.

A recent (and largest to date) multi-center randomized double-blind placebo controlled trial of influenza immunization in 104 MS patients failed to show any difference in attack rate or disease progression over 6 months between vaccinees and placebo recipients (Miller, 1997). This study suggests that even if the vaccine can exacerbate MS, it must do so only among a small minority of MS patients.

Fourth, whether vaccinations actually cause an overall excess of MS in the population (vs. being just one of multiple possible triggers for MS in genetically susceptible individuals, without causing an excess of MS) can only be evaluated in a population-based study. If vaccination only rarely exacerbates MS in MS patients, if at all (Miller, 1997), it is hard to imagine physiologically that vaccinations would cause an excess of MS. 

Although scientific evidence to date does not support hepatitis B vaccination causing multiple sclerosis (MS) or other demyelinating diseases a study is currently being organized in the Vaccine Safety Datalink project at CDC because of public concern about this issue in France and elsewhere and because there is little available research on this specific topic (Chen, 1997). Computerized medical records on approximately 5 million or 2% of the U.S. population are available in this study. It will probably be at least one year, however, before any results are available

In the meantime, the concern regarding a suggested association between vaccination and MS or any other chronic illness must be weighed against the very strong evidence that vaccines have in protecting against disease and death.

How is vaccine safety monitored after it is licensed for use?

The Vaccine Adverse Event Reporting System (VAERS) ensures the safety of vaccines distributed in the United States. VAERS reports are usually submitted by health care professionals or vaccine manufacturers, however any one can submit a report to VAERS. VAERS is administered, monitored and analyzed jointly by the Centers for Disease Control and Prevention and the Food and Drug Administration. Persons who wish to report a possible health effect related to a vaccine should notify their health care provider and can also call the VAERS program at 1-800-822-7967. 

This fact sheet was produced by the CDC; Hepatitis Branch, National Center for Infectious Diseases; and the National Immunization Program; Aug 12, 1998

 Scare of multiple sclerosis from hep B vaccine "quite unfounded". Vaccine and Immunization News: The newsletter of the global programme for vaccines and immunization, WHO. 1997; No. 4: p. 8.

No evidence that hep-B vaccine causes multiple sclerosis. Weekly Epidemiological Record, WHO. 1997; No. 21: pp. 149-152. 

CDC www.cdc.gov/ncidod/diseases/hepatitis/b/ faqb. htm 

 Hepatitis B There are almost 300 million chronic carriers of Hepatitis B in the world. It is spread through contact with infected blood, blood products or body fluids, for example through sexual contact, unsterilised needles and blood transfusions, or contact with blood via small breaks in the skin. Other risk situations include having a shave, tattoo, or having your body pierced with contaminated equipment. The symptoms of type B may be more severe and may lead to long term problems.

Hep-D is spread in the same way, but the risk is mainly in shared needles.


\4 some more on Hepatitis C

Was the major cause of all cases of hepatitis resulting from transfusions and most resulting from intravenous drug use. Because of blood screening, the risk from transfusions is now 1 in 10,000. It can also be transmitted through injuries in the skin. It may also be transmitted sexually. About 10% to 60% of acute hepatitis C patients develop the chronic form, which can also occur without a preceding acute stage.

Hep-C can lead to chronic liver disease. The virus is spread by contact with blood usually via contaminated transfusions or shared needles. Avoiding these is the only means of prevention.

Tattoos, Apr 17, 2001 By ERIC NAGOURNEY Needle Can Add More Than Just a Tattoo. People who get tattooed may be getting more than they bargained for. A new study has found that among the people studied, those with tattoos were nine times as likely to be infected with hep C as people who were not. The potentially deadly infection can lead to cirrhosis and liver cancer.

The study was done by Dr. Robert Haley of the Univ of Texas SW Med Ctr and Dr Paul Fischer of the Presbyterian Hosp of Dallas, and the results were reported in Mar in the journal Medicine.

The researchers studied 626 patients at an orthopedic spinal clinic (chosen because their illnesses were not related to blood-borne infection), and 113 of them (about 18 percent) had at least one tattoo.

The researchers found that one-third of the 52 patients who had gotten their tattoos at commercial tattoo parlors were infected with hep-C, compared with 3.5% of the patients without tattoos. While the risk of infection was higher among patients with a history of injecting drugs, heavy beer drinking or working in hospitals, those factors alone were not as important as having a commercially acquired tattoo.

Most at risk were people with several tattoos or large, complex or multicolored ones. The infection, the researchers said, can be passed through the reuse of needles or dye, poor sterilization techniques or practices like the tattooer's pricking the back of his hand to see if the needle is sharp enough.

The researchers advised people at risk of infection to be tested because treatments exist to destroy the virus before it harms the liver.

-- Hep-C can lead to chronic liver disease. The virus is spread by contact with blood usually via contaminated transfusions or shared needles. Avoiding these is the only means of prevention.

I contracted Hep C in 1981 at the time the Doctor's gave me no info about what to expect. They weren't even sure what type I had (at that time there was no test for hep c) so they called it non A non B. I went on the next ten years with no real symptoms. Then in '91 I was diagnosed with Diabetes. No mention of Hep C, but I was gradually getting more tired and experiencing all types of aches and pains. Then in 1996 I was so tired, so ill and had a huge lump under my left rib cage (my first thought was cancer) that I ended up in ER in Galveston. That's when I found out not only did I have Hep C, but I was in the beginning phase of end stage liver disease. The lump was my spleen which is 5x bigger then it should be. My platelet count is under 50,000 (normal is about 500,00) I am so tired It takes everything to get up and go to work. 

I have arthritic like pain in all my joints and muscle pain and weakness everywhere. My ankles and legs swell up to the point where I can not walk. I have had to have 2 abdominal taps for Ascites (fluid buildup in abdomen) I some times look and feel like I am 6 months pregnant. I have been told that I will probably need a liver trans- plant in the next couple of years. I have enlarged eso- phageal veins which can rupture and cause hemorrhaging. Hep-C is a slow silent killer. So far I have been lucky with Doctor's and they understand I do have chronic pain of many kinds and have me on Darvon 65mg every 4-6 hours. My latest Doctor does monitor my consumption quite closely (they don't want me to get addicted) well the pain is not going away and they say they can only treat symptoms so does it matter? I also have to take fuerisomide and aldactone for water retention, I am on Zoloft 25mg for depression (you can not take large doses of anti-depressants because they can damage the liver even more),

I take 4 shots of insulin a day, I take compazine for naseua. A major problem I have is taking one of the medications to help one condition and having it aggravate another condition. If I take my insulin the way I am supposed to I swell up so bad I can't walk and I get Ascites and have to be on complete bed rest for 3-4 days or I end up in the hospital. If I take the medication for swelling it makes me nauseated and very weak. My life since '96 has been filled with Doctor's, every lab test know to man, and I have had cat scans, MRIs, Dye injected in my veins, an endoscopy and colonoscopy, barium enema (this was the worst of them all). It may take 10-20 years before you start showing symptoms but usually by that time the damage has been done and it is irreversible. Hep C does not go away. If you have a Doctor telling you that, get another Doctor. If you have been diagnosed with Hep C early get a Doctor who will do everything to treat those early symptoms this could greatly prolong your life
 Dec 15 1998 Hepatitis: How Widespread a Threat?By DENISE GRADY

Three years ago, when Patricia Buchanan, a 43-year-old woman living in Brooklyn Park, Minn., consulted her doctor about fatigue and a vague feeling of illness, she expected to be told that her problems were due to smoking and excess weight. 

But the diagnosis turned out to be much worse: She had hepatitis C, a viral infection of the liver. She had probably been infected 15 or 20 years  before, her doctor said, and, like 85 percent of all patients, she had developed a chronic infection, meaning that the virus had lingered in her  body for years. 

The vast majority of people with chronic hepatitis C carry the virus indefinitely, apparently with few ill effects. But about 20 percent develop cirrhosis and liver failure or cancer within 20 to 25 years of being infected, and 8,000 to 10,000 a year in the United States die as a result of contracting hepatitis C, which has become the leading reason for liver transplants. 

Mrs. Buchanan's lab tests and a biopsy revealed scarring of the liver, indicating that she might be one of the unfortunate ones in whom the disease would worsen. Hoping to prevent further liver damage, her doctor recommended drug treatment to try to rid her system of the virus. Mrs. Buchanan, who has four grown children and runs her own business, a ceramics studio, had never even heard of hep C. "I was terrified," she said. 

During the next two decades, more and more Americans are expected to find themselves in the same situation. Most will be middle-aged people who feel fine now, but who will become ill, as Mrs. Buchanan did, and find out they were infected years ago. Others, still well, will receive letters from the Govt and blood banks as part of a pgm to inform 300,000 people who may have been infected by transfusions before 1992, when a test for the hep C virus came into use. 

For people like Mrs. Buchanan, with clear signs of liver damage, doctors strongly recommend treatment. But those who test positive for the virus but have no signs of disease will face difficult questions about whether to start treatment, because it is expensive, complicated by severe side effects and, in more than half of patients, unable to eradicate the virus. Treatment is generally not recommended for those without signs of liver damage, but regular monitoring is, because in the early stages of infection it is impossible to tell whether the disease will progress. 

The CDC estimates that four million Americans are infected with hep C, and most of them do not know they are carrying it. 

Those who know they need treatment may find themselves caught in a controversy similar to the ones that have erupted over high-priced treatments for AIDS. Their interests have collided with those of a pharmaceutical company eager to recoup its research expenses and turn a profit. Meanwhile, some researchers say that the company, the Schering-Plough Corporation of Madison, N.J., is needlessly alarming Americans about the disease in its advertising. Hep C is spread mainly by exposure to infected blood. There is no vaccine. 

Before the test for the virus came into use, transfusions were the main route of transmission. Since then, the nbr of new infections has plummeted. But Schering has called the disease an epidemic in its advertising and has featured on its Web site illustrations of people with the hideously yellow eyes of jaundice, a symptom of severe liver disease. "To put it bluntly," the ads say, "every living, breathing human being can get hep C even you." The Lancet, a British medical journal, says the advertising campaign has "breached the public trust." But in a telephone interview, Robert Consalvo, a spokesman for Schering, said the word "epidemic" was reasonable, given that hepatitis C infects 4 million Americans and is the leading blood-borne infection in the nation. In a letter to the Lancet, Schering said, "we believe it is in the public's best interest to provide as much info about potential risk factors as possible so that individuals can take the appropriate steps to protect themselves against possible infection." 

Dr. Leonard Seeff, a senior scientist for hepatitis C research at the National Institute of Diabetes and Digestive Diseases, said, "The inference  from the word 'epidemic' is that people are getting infected like crazy, and that's not so." Dr. Seeff said he worried that fears about the disease, and the pressure to test and treat everyone, would lead people infected with the virus to take expensive drugs with potentially serious side effects, whether they need them or not. He said more than 80% of those infected with the virus "will survive with no disease whatsoever." But he added that people with the virus must never drink alcohol, because it accelerates liver damage from the infection. 

Consalvo said Schering scientists believed that the earlier patients start  treatment, the better their chances of getting rid of the virus.  Dr. Jay Hoofnagle, director of the division of digestive diseases and nutrition at the NIH, said: "There's no epidemic going on now of hep C. New cases have fallen precipitously since the discovery of the virus. The epidemic, if it occurred, occurred during the  60's and 70's, when there was a lot of experimentation with drugs, and the virus got into the population that donated blood. 

People infected then are now turning 50 and 60, at which point hepatitis C rears its head." Because some of those people will fall ill, a substantial increase is  expected in the demand for liver transplants, though donor organs are already in short supply. Hepatitis deaths are also expected to increase,possibly doubling or tripling to 20,000 or 30,000 a year within a decade or so. But the number of deaths will probably peak and then decline again, because of the decline in new infections, Dr. Seeff said. According to a report issued in Oct by the Centers for Disease Control and Prevention, there were an estimated 230,000 new infections each year through the 1980's. By 1996, the figure had dropped to 36,000. 

Today, the most common means of transmission is the sharing of needles by drug users, which accounts for 60 percent of new infections in the US. Among those who have injected drugs for five years, 90 percent are thought to be infected. For the remaining 40% of people infected in the US, the origin of the infection is less clear. Although sexual contact does not seem to spread hep C efficiently (unlike the AIDS and hepatitis B viruses),20% of infected people report no other means of exposure. Another 10% are thought to have been infected while working at a hospital, undergoing hemodialysis for kidney failure, during birth, or by sharing a toothbrush or razor or being exposed in some other way to infected blood.

For the final 10%, there is simply no explanation for the infection.  Despite widespread warnings about tattooing and body piercing -- and the  common-sense assumption that dirty instruments could spread the virus --  there is no evidence linking those practices to the disease in the US, according to the Centers for Disease Control. Similarly, manydoctors suspect that people can transmit the virus by sharing the strawsused to inhale cocaine, but researchers are not sure whether that has  occurred. 

Mrs. Buchanan said she belongs to the "no explanation" group, having never  received a transfusion or taken drugs. Her husband and other family members  all tested negative for the virus, she said.  In 1995, when she first learned she was infected, Mrs. Buchanan enrolled in  a study that provided six months of treatment with Schering-Plough's version  of the drug interferon, which eliminates the virus in 10 to 20 percent of  patients. But half of patients do not respond to interferon at all, and Mrs.  Buchanan was one of those. At the time, interferon was the only treatment  available.  But in June, a new treatment was approved by the Food and Drug  Administration, a combination therapy that paired interferon with the  antiviral drug ribavirin. The combination, Rebetron, made by  Schering-Plough, reduced the virus to undetectable levels in about twice as  many patients as interferon did. 

Even when it worked, Rebetron was not considered a cure, and it had terrible side effects, including anemia, depression, suicidal thoughts and severe flu-like symptoms. Nonetheless, Mrs. Buchanan wanted to try the combination treatment. But because Schering-Plough's brand of interferon had not worked for her, she hoped to purchase the ribavirin alone and combine it with another form of interferon, a slightly different one made by another company. She had researched it on her own, and thought it might work better for her. Her doctor agreed it was worth a try.

She quickly found out that would not be possible. Schering-Plough had "bundled" the two drugs, packaging them together as a kit. Patients could  buy Schering's interferon alone, but not ribavirin. A company spokesman said the product was packaged that way because there was no approved use for ribavirin except in combination with interferon as a treatment for hep C.

Because Schering-Plough had the exclusive right to market ribavirin in the US, there was no other way to buy it. Mrs. Buchanan did not want to purchase the entire kit -- a six-month supply costs $6,400 to $8,600 -- just to get the ribavirin. A spokesman for Schering said the price of Rebetron reflected the hundreds of millions of dollars it has cost to develop the product. 

The bundling of Rebetron, which might seem a stroke of marketing genius to a drug company, looked like a dangerous precedent to people with hep C. Many, like Mrs. Buchanan, wanted to mix ribavirin with another company's interferon, and some, particularly people who had received liver transplants, needed smaller doses of interferon than the kit provided, but would be forced to throw away the extra medication because it was  perishable. 

The bundling also sent up a red flag among advocates for AIDS patients. Some people taking a host of drugs to treat H.I.V. also have hepatitis C, and  want as much flexibility as possible in picking medications. The AIDS groups began showing hepatitis patients how to do battle with big drug companies. 

Jeff Getty, who is active in AIDS issues in San Francisco, said, "The H.I.V. and AIDS community is watching this and very much up in arms about it, because we know what it means for us." Getty said he feared that companies would similarly bundle combination treatments for AIDS, interfering with doctors' ability to prescribe different combinations for patients. "Where does it stop?" Getty asked. "Do I have to buy their Kleenex taped to their nose spray, because they were tested together? This is wrong." One AIDS group has begun buying ribavirin from Mexico, which imports it from an American company. The group provides it to hepatitis C patients at cost, which comes to less than half what ribavirin would cost in the bundled product. 

Patients and advocacy groups asked the Food and Drug Administration to require that Rebetron be unbundled, but Dr. Heidi Jolson, director of the division of antiviral drugs at the agency, said its lawyers had determined that it lacked the regulatory authority to do so. Dr. Jolson did write to Schering-Plough, saying that the product did not have to be bundled and that the agency would cooperate if the company decided to sell the drugs separately. 

Robert Consalvo, a spokesman for Schering-Plough, said that the company has listened to the concerns of patient advocates and is developing a program to help provide ribavirin to hepatitis patients whose doctors can prove that the patients have a need for it. The program will start in January, he said, though patients who need help sooner may get it if their doctors contact the company. That was news to Mrs. Buchanan, who said her letter to the company had never been answered. - April 11, 2000 Old Blood Samples Offer New Clues to a Medical Mystery

By GINA KOLATA WASHINGTON -- Fifty years ago, when he was 19, Edward J. Woodland Jr.  joined the Air Force. In Wyoming for basic training, he and some of  his fellow recruits gave blood samples for a study of strep throat.  Mr. Woodland, a retired security guard who lives in Washington, had  long since forgotten about that study. 



People with hepatitis C, and no symptoms, raise new questions.




But he heard of it again in February when he got a three-page letter  from a government scientist whose group had found the blood samples in  a freezer in Minneapolis, tested them for something entirely unrelated  and tracked him down after all these years. The hope was that Mr.  Woodland might provide vital clues to an abiding medical mystery: what  is the natural course of hepatitis C?  Some hepatitis specialists say the virus is usually not very  worrisome. Others say that it is a terrifying national epidemic and  that everyone who is infected should be found and treated. But the  treatment is expensive, unpleasant and not very effective, so medical  experts feel an urgent need to discover just how bad the disease is.  Mr. Woodland and others in the study may help them find out.  Now Mr. Woodland sits erect in a narrow wooden chair in the office of  Leonard Seeff, the doctor who wrote the letter, having learned for the  first time the details of his extraordinary medical situation.  No one knew that the variety of hepatitis now known as hepatitis C  even existed 50 years ago, yet Mr. Woodland is living proof that it  did and that healthy young teenagers were being infected. He is also  living proof that infection with hepatitis C need not be a death  knell, or even a threat to health. Millions of copies of the virus  still course through Mr. Woodland's bloodstream and burrow into his  liver. Yet, in defiance of conventional medical wisdom, he has not had  any overt signs of illness.  For Dr. Seeff, the story of Mr. Woodland and a handful of his fellow  recruits is a cautionary tale for hepatitis researchers that raises  thorny questions about the study and treatment of hepatitis C. 

Scientists estimate that 3 million to 5 million Americans are infected  with the hepatitis C virus, which can smolder quietly in the liver for  decades before erupting as cirrhosis, liver failure or liver cancer.  Some were infected from blood transfusions in the years before the  early 1990's, when a blood test for the virus was developed and came  into use. Others got it from sharing contaminated needles. It can also  be transmitted sexually.  But there are also people, like Mr. Woodland, who neither used drugs  nor had transfusions, who will never know how or when they became  infected. Since it can take years for symptoms to develop, most who  are infected do not know it.  Some say that hepatitis C is a time bomb ready to explode in the next  few decades as hundreds of thousands of Americans, most of whom do not  know they are infected, become ill. Dr. C. Everett Koop, the former  surgeon general, who has campaigned to publicize the dangers of  hepatitis C, has called the disease a grave threat to public health.  "Unless we do something about it soon," he has written, "it will kill  more people than AIDS."  Others say that while hepatitis C can be deadly, most people who are  infected with it either recover spontaneously or never become ill in  the first place. Most people carrying hepatitis C, they say, live  normal life spans and die of something other than liver disease.  "Just because you have hepatitis C doesn't mean your life is ruined,"  said Dr. Miriam Alter, chief of the epidemiology section at the  hepatitis branch of the federal Centers for Disease Control and  Prevention in Atlanta.  But treatment for hepatitis C is far from ideal. Most patients must  spend a year injecting themselves with the drug interferon, which both  fights the virus and stimulates the immune system to attack the virus,  and taking ribavirin pills, a drug that strengthens the effects of  interferon.  The drugs are unpleasant to take, causing flulike symptoms, including  fever, lethargy, malaise, and achiness. They can also cause severe,  even suicidal, depression. And they eradicate the virus in only 30  percent to 40 percent of patients. For blacks, like Mr. Woodland, the  treatment rarely works, for reasons that remain unclear.  Doctors fall into two broad groups, said Dr. Harvey Alter (who is not  related to Dr. Miriam Alter) , chief of the infectious disease section  at the National Institutes of Health. "One group says you cannot  predict the outcome of hepatitis C, therefore it is safest to treat  everyone," Dr. Alter said. "The other group feels that most people are  not badly affected and that this disease progresses slowly."  If doctors follow the patients, Dr. Alter said, "it is safe to wait  and see if there is significant progression," before starting  treatment.  "The dilemma is only because the treatment is difficult," Dr. Alter  said. "If we had a safe and effective oral treatment, we would treat  everybody." But, for now, the question of whether to treat, and whom  to treat, hinges on the larger question of how bad hepatitis C is. And  that question hinges on studies of people like Mr. Woodland.  Until now, research on hepatitis C has focused on patients who sought  help from liver specialists. Often, they were the sickest patients,  suffering from liver failure or liver cancer. Their experience shows  how serious hepatitis C infections can be. But researchers have no  idea if they are typical.  Other studies have traced the virus and its effects in people who were  infected through contaminated blood about two decades ago. In those  studies, very few infected people turned out to be sick, but that  might be because the studies have not gone on long enough or because  patients who might have gotten liver disease died first of the  diseases that led to the transfusion.  It seemed there was no way to learn the true picture, since no one  knew how to find people who had been infected so long ago.  Then, by chance, Dr. Richard Miller, a doctor and medical  epidemiologist at the Walter Reed Army Institute of Research in  Washington, learned that blood had been saved from the strep throat  study.  From 1948 to 1954, while strep infections raged at the Fort Francis E.  Warren Air Force Base in Wyoming, doctors there conducted a landmark  study that eventually proved that treating the bacterial infections  with antibiotics could prevent rheumatic fever, a grave heart  condition that can follow strep throat.  The blood samples, from 9,427 recruits, ended up in a freezer in  Cleveland, where the lead strep investigator, Dr. Charles Rammelkamp,  had moved. Twenty years ago, when Dr. Rammelkamp was ready to retire,  he offered the blood to Dr. Edward L. Kaplan, a strep researcher who  is at the University of Minnesota. If Dr. Kaplan had not wanted the  blood, it would have been discarded.  Dr. Kaplan used freezer trucks that normally carry frozen pizzas to  bring the blood back to Minnesota. To store the 83 wire trays, each  holding about 700 vials of blood, he and his 10-year-old son went to  Sears and bought freezers. "The salesman asked me if I owned a rest," Dr Kaplan recalled. He kept the blood and dreamed of using it some day. 

Dr Miller invited Dr Seeff, who is senior scientist for hep C research at the National Institute of Diabetes and Digestive and Kidney Diseases and a liver disease specialist at the VA Med Center in Washington, to help use the blood to ask whether the hep C virus had existed 50 years ago and, if it had, what had happened to people who had been infected. 

All they had to do was test the blood and track down anyone who had been infected. Dr Miller, who had moved to the medical follow-up agency of the National Academy of Sciences, could get death cert and other crucial medical info. First, Dr Seeff and Dr Miller consulted with ethi- cists to determine whether this was the right thing to do. Dr. Miller was told that there would be no problem but Dr. Seeff got conflicting opinions. Some ethicists told him to go ahead but others said he should first get permission from each man, a task that Dr Seeff concluded was logistically impossible. 

There was no policy at the National Institutes of Health prohibiting the study, so Dr. Seeff decided to go ahead with it. The investigators focused on the 8,568 men in the study who had Social Security numbers, allowing federal scientists to trace them. 

Blood tests showed that 17 men had been infected with the hep C virus when they were at that Air Force base during the Korean War, the same percentage as is found among healthy young military recruits today. Seven of the men had since died, but only one had had chronic liver disease. He had died of liver disease 42 years after his stint at the Air Force base. But what about the others? Two had no known addresses, but eight did. 

For a year and a half, Dr. Seeff worked on a letter to send these men, consulting with ethicists and other doctors, writing draft after draft. He knew the risks: the men could be repelled by the idea of govt scientists tracking them down after all these years, they might simply throw the letter away, they might be terrified by the news that doctors had found a dread virus in their 50-year-old blood. 

The final version was almost bland, calling the quest "a very meaningful study" and "this important study." The men were told, "Your contribution to the project may help not only yourself but many others who might have persis- tent hep C or who will become infected in the future." 

Finally, on Feb. 1 the letters went out by Fed Ex. Two days later, the first man called. Within a week, Dr Seeff had heard from all eight. All but one, who had had a stroke, were willing to be examined. The three men tested so far are still infected with hep C, Dr. Seeff said. 

Mr Woodland was the first to come in for testing and his results were totally unexpected. They showed 3.18 million copies of the hep C virus in his blood and slightly abnormal liver enzymes, indicating an infection. "I am more amazed by this than by almost anything I have ever seen," Dr Seeff said. "This man has had 50 years of infection," he said. Yet, he continued, Mr Woodland seems to have simply lived with the virus, with no signs of illness. Dr Seeff was not sure what to say to Woodland. 

If Mr. Woodland had simply showed up in Dr Seeff's office that day, without the old blood sample indicating that he had had hep C for 50 years, Dr. Seeff knew what he would have done. "I would say, 'Let's do a liver biopsy and if he has cirrhosis, let's treat him.' " But, Dr Seeff said: "Here's a man who's 69 years old. He's been pos for 50 years. Treatment couldn't have done a better job. The question is, do you impose treatment on him? 

Dr. Seeff put the choice to Mr. Woodland. While Mr. Woodland sat in his office that rainy afternoon late last month, Dr. Seeff nervously told him that he still had hep C and that the only way to know if the virus had damaged his liver was to have a biopsy. He asked Mr Woodland to think it over and to get back to him. 

Mr Woodland was outwardly calm. "I've got to think about it," he said. "If it's best for me to have treatment, I'll get treatment." He signed up to be a patient at the medical center and went home. Dr. Kaplan said some scientists had criticized the study because it found so few men with hep C. 

"Yes, it's a small number," Dr. Kaplan said. "And yes, one could be critical of the small number. But it goes against a pervasive thought that the diagnosis of hep-C borders on a death warrant. If it does nothing more than to say to people that we should look at that assumption again, then it has served its purpose." 


\5 some more on Hepatitis E

Hep-E is transmitted in the same way, it can be very serious in pregnant women.

Hepatitis E (HE) is a recently described infection of the liver which is common in many developing countries.

Like hepatitis A, it is spread by drinking contaminated fluids or eating contaminated food. It occurs both in epidemics, affecting many people over a short time, and sporadically - individual cases [Reference Library] occurring here and there. Adolescents and young adults are principally affected. While complete [Image] recovery is the rule and there is no long-term carrier state, the illness can be debilitating and very [Travel Products]unpleasant and may last a few weeks to a few months.

Hepatitis E is rarely fatal, except in pregnant women, who are most vulnerable to this disease. The death rate of hepatitis E is substantially increased in pregnancy, particularly in the later stages - around 20% of pregnant women who develop HE in the third trimester will die as a result. While hepatitis E has been acquired in the Northern Territory, almost all cases occurring in Australia have been acquired overseas by migrants and refugees arriving in Australia, or by Australians travelling abroad. A number of such cases have been documented.

Apart from humans, a number of animals (such as pigs & rats) can be infected with hepatitis E.

Why Study Hepatitis E in Travellers to Nepal ? Nepal appears to be among the highest, if not the highest, risk area for acquiring hepatitis E in the world. Outbreaks in the Kathmandu Valley generally occur each wet season (May-September), with larger epidemics every few years.

One of the world’s major pharmaceutical companies manufacturing vaccines, SmithKline/Beecham (based in Belgium), has the rights to a promising candidate vaccine against hepatitis E. Before proceeding with full scale commercial development of the vaccine, the company needs further information about the risks and consequences of hepatitis E in various groups of people in different parts of the world. In order to establish the need for a HE vaccine, this research will also identify groups in which such a vaccine could best be studied (to ensure it is safe and effective) and later used more widely.

This study is part of this global research effort, involving travellers going to Nepal from Australia, and also from Germany, Austria and Switzerland.

What are the benefitis of the study ? There is currently no good information available on how commonly travellers become infected with hepatitis E and what the consequencies of these infections are. This study will seek the answers to these questions. If hepatitis E is shown to be a common or serious illness in travellers, this will encourage development of an effective vaccine, sooner rather than later. This vaccine can then be used to protect travellers and others at risk in areas where hepatitis E occurs, particularly pregnant women.

How will the results of the study be used? report of the overall study findings will be used by SmithKline/Beecham to make decisions about further development and use of HE vaccine. Hopefully, it will provide the basis for trials evaluating the effectiveness and safety of HE vaccine, enabling subsequent widespread avilability and use of the
 vaccine. The results of the study will also be published in an international medical journal.

-- Hepatitis E Virus
 1. Name of the Organism:
 Hepatitis E VirusHepatitis E Virus (HEV) has a particle diameter of 32-34
 nm, a buoyant density of 1.29 g/ml in KTar/Gly gradient, and is very
 labile. Serologically related smaller (27-30 nm) particles are often found in feces of patients with Hepatitis E and are presumed to represent degraded viral particles. HEV has a single-stranded polyadenylated RNA
 genome of approximately 8 kb. Based on its physicochemical properties it is presumed to be a calici-like virus.
 
 2. Name of Acute Disease:The disease caused by HEV is called hepatitis E,
 or enterically transmitted non-A non-B hepatitis (ET-NANBH). Other names
 include fecal-oral non-A non-B hepatitis,and A-like non-A non-B hepatitis.
  Note: This disease should not be confused with hepatitis C, also called parenterally transmitted non-A non-B hepatitis (PT-NANBH), or B-like non-A non-B hepatitis, which is a common cause of hepatitis in the U.S.
  3. Nature of Disease:Hepatitis caused by HEV is clinically indistinguishable from hepatitis A disease. Symptoms include malaise,
 anorexia, abdominal pain, arthralgia, and fever. The infective dose is not known.
  4. Diagnosis of Human Illness:Diagnosis of HEV is based on the epidemiological characteristics of the outbreak and by exclusion of hepatitis A and B viruses by serological tests. Confirmation requires identification of the 27-34 nm virus-like particles by immune electron microscopy in feces of acutely ill patients.
 
 5. Associated Foods:HEV is transmitted by the fecal-oral route. Waterborne
 and person-to-person spread have been documented. The potential exists for foodborne transmission.
  6. Frequency of Disease:Hepatitis E occurs in both epidemic and sporadic-endemic forms, usually associated with contaminated drinking
 water. Major waterborne epidemics have occurred in Asia and North and East Africa. To date no U.S. outbreaks have been reported.
  7. Usual Course of Disease and Some Complications:The incubation period for hepatitis E varies from 2 to 9 weeks. The disease usually is mild and resolves in 2 weeks, leaving no sequelae. The fatality rate is 0.1-1%
 except in pregnant women. This group is reported to have a fatality rate approaching 20%.
  8. Target Populations:The disease is most often seen in young to middle
 aged adults (15-40 years old). Pregnant women appear to be exceptionally
 susceptible to severe disease, and excessive mortality has been reported in this group.
  9. Analysis of Foods:HEV has not been isolated from foods. No method is currently available for routine analysis of foods.
 
 10. History of Recent Outbreaks:Major waterborne epidemics have occurred in India (1955 and 1975-1976), USSR (1955-1956), Nepal (1973), Burma (1976-1977), Algeria (1980-1981), Ivory Coast (1983-1984), in refugee
 camps in Eastern Suddan and Somalia (1985-6), and most recently in Borneo
 (1987). The first outbreaks reported in the American continents occurred
 in Mexico in late 1986. To date, no outbreak has occurred in the U.S., but imported cases were identified in Los Angeles in 1987. There is no evidence for immunity against this agent in the American population. Thus, unless other factors (such as poor sanitation or prevalence of other enteric pathogens) are important, the potential for spread to the U.S. is great. Good sanitation and personal hygiene are the best preventive measures.
 
Hep-E is similar to hepatitis A and is transmitted by contact with contaminated food or water. It was thought to be rare, but experts now estimate that up to 20% of people in the US may be infected, even those who haven't traveled.

Hepatitis E is transmitted in the same way as hep-A, it can be very serious in pregnant women. There are 300 mil chronic carriers of Hep-B in the world. It is spread through contact with infected blood, blood products or body fluids, for example through sexual ctc, unsterilised needles and blood transfusions, or contact with blood via small breaks in the skin. Other risk situations include having a shave, tattoo, or having your body pierced with contaminated equipment. The symptoms of type B may be more severe and may lead to long term problems. 


\6 some more on Hepatitis G

Hep-G accounts for about 9% of cases that cannot be diagnosed as hepatitis A through E. It also occurs in about 25% of patients with of hepatitis A, 32% of those with hep-B, and 20% of patients with hep-C. Hep-G appears always to be chronic, but to date indications are that it is mild and does not even increase the severity of any accompanying hepatitis virus.


\7 Leptospirosis (Weil)

Infection caused by bacteria in contaminated water, soil, urine of infected dogs or rodents. ncubatioon period 1-3 weeks. Chills, fever, severe muscle and head ache. Poss liver and kidney damage.
The illness lasts from a few days to 3 weeks or longer. Without treatment, recovery may take several months. seek medical care. Antibiotics are effective.
eptospirosis is a bacterial (genus Leptopira) disease that affects humans and animals. In humans it causes a wide range of symptoms, but some infected persons may have no symptoms at all. Symptoms of leptospirosis inc high fever, severe headache, chills, muscle aches, and vomiting, and may inc jaundice (yellow skin and eyes), red eyes, abdominal pain, diarrhea, or a rash. If the disease is not treated, the patient could develop kidney damage, meningitis (inflammation of the membrane around the brain and spinal cord), liver failure, and respira- tory distress. In rare cases death occurs.
Many of these symptoms can be mistaken for other diseases. Leptospirosis is confirmed by lab testing of a blood or urine sample. People get leptospirosis from water or food contaminated with the urine of infected animals especially w/mucosal surfaces, as the eyes or nose, or broken skin. The disease is not known to be spread from person to person. Many diff kinds of animals carry the bacterium; they may be sick but sometimes have no symptoms. The organisms have been found in cattle, pigs, horses, dogs, rodents, and wild animals.

The time between a person's exposure to a contaminated source and becoming sick is 2 days to 4 weeks. Illness usually begins abruptly with fever and other symptoms. Leptospirosis may occur in two phases; after the first phase, with fever, chills, headache, muscle aches, vomiting, or diarrhea, the patient may recover for a time but become ill again. If a second phase occurs, it is more severe; the person may have kidney or liver failure or meningitis. This phase is also called Weil's disease. Leptospirosis occurs worldwide but is most common in temperate or tropical climates. It is an occupational hazard for many people who work outdoors or with animals, eg, farmers, sewer workers, veterinarians, fish workers, dairy farmers, or military personnel. It is a recre- ational hazard for campers or those who participate in outdoor sports in contaminated areas and has been assoc with swimming, wading, and whitewater rafting in contaminated lakes and rivers. The incidence is also increasing among urban children. Leptospirosis is treated with antibiotics, such as doxycycline or penicillin, which should be given early in the course of the disease. Intravenous antibiotics may be required for persons with more severe symptoms. Persons with symptoms suggestive of leptospirosis should contact a health care provider. The risk of acquiring leptospirosis can be greatly reduced by not swimming or wading in water that might be contaminated with animal urine. Protective clothing or footwear should be worn by those exposed to contaminated water or soil because of their job or recreational activities.

The Leptospira interrogans, cause of a disease transmitted from animals to humans.
 After falling out of her raft on a whitewater expedition this spring in the Costa Rican rain forest, Dr. Nicole MacLaren was so grateful she was alive that it did not occur to her that her near-drowning might lead to something else — a potentially fatal bacterial infection called leptospirosis. But four days after returning to Park City, Utah, Dr. MacLaren, 37, developed the first signs of infection: a fever that soared to 103.5 degrees and drenching sweats that alternated with chills so severe they felt almost like a seizure. Dr. MacLaren, a veterinary ophthalmologist, had a splitting headache, and her eyes and muscles ached. In the emergency room, her kidney and liver were found to be inflamed. The effect on the kidney and the discovery that she also had meningitis suggested that she had leptospirosis, but her joint aches made dengue fever, a mosquito-borne illness that causes severe joint pain, a suspect as well. Malaria had been ruled out by a blood test. All three illnesses are found in the Costa Rican rain forests. She was treated with intravenous antibiotics on the assumption that she had an infection, and leptospirosis was confirmed in her three-day hospital stay. "It was terrifying, because as a vet, I'd dealt with so many cases that had died," said Dr. MacLaren, referring to leptospirosis she had treated in dogs. The corkscrew-shaped Leptospira interrogans has been on earth as long as its host mammals — mostly dogs, pigs, cattle and rats. The bacterium, which has 250 pathogenic strains, causes leptospirosis, the most common disease transmitted from animals to humans. There are not good numbers on leptospirosis incidence, but health officials and some researchers say that as people venture more boldly into remote wilderness, there is likely to be an increase. "We suspect that as people pursue these kinds of activities more and more, as we venture into areas where essentially human populations have not spent time before, this may continue to increase," said Dr. Jim Sejvar of the meningitis and special pathogens branch at the Centers for Disease Control and Prevention. The illness is not easily recognized by doctors, even though it has long been seen as a scourge in developing nations. Under the right conditions — high heat and humidity — the bacteria, which are shed in animal urine, can live on the ground for weeks or months. Torrential rains carry the leptospires from riverbanks, grass, jungle floors or dirty streets and alleys into places where people are playing or living. People get sick by swallowing contaminated water or by getting it in their eyes or in open cuts. Fever and nausea or vomiting occur two days to a month after the bacteria have colonized the entire body. Antibiotic treatment is usually needed, and in many people — it is not clear why — the leptospires run amok, leading to kidney and liver failure, meningitis and, sometimes, death. The Centers for Disease Control and Prevention recently confirmed a leptospirosis outbreak in 30 American athletes in the Eco-Challenge Expedition Race who likely became ill by swimming and canoeing in the flooded Segama River, which runs through a dense rain forest in Malaysian Borneo. The jungle is inhabited by rats, civet cats, bearded pigs, monkeys and orangutan. No racers died, but at least 12 were hospitalized, and the C.D.C. urged them all to be treated. A similar outbreak occurred in the United States in 1998, when 110 of 775 triathletes contracted leptospirosis after swimming in Lake Springfield in Illinois. Dr. Joe Vinetz, a leptospirosis expert, who is a professor at the University of Texas Medical Branch in Galveston, said he believed the disease was re-emerging because of greater participation in adventurous activities and the growing interaction between rats and people in urban areas. Cleaning up after rats and dogs is difficult, which means more urban residents are coming into contact with leptospira-laden urine, Dr. Vinetz said. He also said people in developing countries were becoming more vulnerable as poor areas — and their often ubiquitous rats — sprawled. Dr. Vinetz surprised other researchers in 1996 by proving that three inner-city Baltimore residents with unexplained flulike illnesses had leptospirosis, contracted by walking barefoot through alleys. Of the 21 rats from those alleys that Dr. Vinetz tested, 19 carried leptospires. Forty percent of the cattle at a Texas slaughterhouse Dr. Vinetz surveyed recently were carrying the bacteria. That is tenfold higher than previous tests of cattle in the United States, Dr. Vinetz said.. The C.D.C. and the World Health Organization agree that leptospirosis has historically been underreported. So it is hard to know whether leptospirosis is on the rise, or if cases like the Eco-Challenge outbreak and Dr. MacLaren's infection will cause increased awareness and thus, more reports. American doctors are not required to report suspected cases, and they often will not try to confirm them, since only two laboratories in the United States are equipped for testing — the C.D.C.'s in Atlanta and the World Health Organization's Collaborating Center for Tropical Diseases, at the University of Texas in Galveston. Not surprisingly, only 100 to 200 cases are tallied each year, about half in Hawaii, which has conditions favorable for leptospirosis. "There are likely cases throughout the U.S. that go undiagnosed," Dr. Sejvar said. Dr. Vernon Ansdell, an internist who specializes in tropical and travel medicine at Kaiser Permanente in Honolulu, agreed. "I think it's certainly being underdiagnosed, even in a place like Hawaii where we have a fair index for suspicion," he said. Many cases of unexplained meningitis may be due to leptospirosis, said Dr. David Haake, a professor at the University of California at Los Angeles. Since these people are treated and cured with antibiotics, a definitive diagnosis is not usually made. International data were first collected by a survey of World Health Organization members in 1996. Results were published three years later. In that time, almost a half million cases were reported in China alone. Brazil had almost 30,000 cases, estimating 250 deaths a year. Mortality rates for those who become infected can be as high as 25 percent, especially in developing nations. If so, leptospirosis kills more people than the Ebola virus, Dr. Vinetz said. Hal Karp, a 36-year-old freelance writer and editor in Dallas, did not have to travel to get leptospirosis. He contracted it from his dog, Buddy. Mr. Karp deduced that Buddy was infected from grass or water contaminated with urine from cattle at a rodeo across the street from his kennel. As Buddy got sicker, Mr. Karp spent more time with him, coming into contact with the dog's urine. Not realizing he had been exposed, he ignored a fever and headaches that began shortly after Buddy was euthanized. Mr. Karp started antibiotics on the advice of an infectious disease specialist who confirmed his leptospirosis. Mr. Karp's pregnant wife took preventive antibiotics, since leptospirosis can cause miscarriage. She delivered a healthy baby and did not become ill. Studies have shown that doxycycline works as a preventive. Some Eco-Challenge racers took the drug as an anti-malarial, and did not get leptospirosis. Dr. MacLaren said she wished she had been warned to take doxycycline before her trip. Five months later, she is still weak, and has only recently gone back to her veterinary practice part time. She is still grappling with what happened. "As a tourist, you don't expect to get something that could kill you."


\8 Lyme Disease

A tick-transmitted bacterial infection which may be acquired throughout NA, Europe and Asia. If untreated, symptoms usually resolve over several weeks but over subsequent weeks or months disorders of the nervous system, heart and joints may develop. Treatment is best early in the illness. Medical help and blood test should be sought ASAP if suspect. Circular sore/rash at bite site, joint or glands, fever, swelling, headache, fatigue. A tick take 4-12 hrs to transmit the disease. If a tick is found, extract and save for analysis. Responds to treatment with antibiotics, best to begin at at onset. Untreated, it can lead to heart, joint, and nervious system problems and may be fatal. Most cases are undiagnosed and untreated for years. Vaccine available 12/98, taken over 15 mths, 80% effective. Lyme disease is an infection caused by the corkscrew- shaped bacteria Borrelia burgdorferi that is transmitted by the bite of deer (Ixodes scapularis) and western black-legged (Ixodes pacificus) ticks. The deer tick, which normally feeds on the white-footed mouse, the white-tailed deer, other mammals, and birds, is responsible for transmitting Lyme disease bacteria to humans in the NE and N.cen US. On the Pacific Coast, the bacteria are transmitted to humans by the western black-legged tick.
 The deer tick (Ixodes scapularis) adult female & male, nymph, and larva on a cm scale. much smaller than common dog and cattle ticks. In larval and nymphal stages, are no bigger than a pinhead. Adult ticks are slightly larger. Ticks feed on blood by inserting their mouth parts into the skin of a host animal. They are slow feeders: a complete blood meal can take several days. As they feed, their bodies slowly enlarge.
 The number of annually reptd cases of Lyme disease in the US has increased about 25-fold since nat surveillance began in 82, and a mean of approx 12,500 cases annually were reported by states to the CDC from 93-97. In the US, the disease is mostly localized to states in the NE, mid- Atl, and upper N.cen regions, and to several counties in NW Calif.
 Most B. burgdorferi infections are thought to result from periresidential exposure to infected ticks during prop- erty maint, recreation, and leisure activities. Thus, individuals who live or work in residential areas surro- unded by woods or overgrown brush infested by vector ticks are at risk of getting Lyme disease. 

In addition, persons who participate in recreational activities away from home such as hiking, camping, fish- ing and hunting in tick habitat, and persons who engage in outdoor occupations, such as landscaping, brush clear- ing, forestry, and wildlife and parks mgmnt in endemic areas may also be at risk of getting Lyme disease.

Lyme disease is a tick-transmitted infection which may be acquired throughout N.Amer, Europe and Asia. The illness usually begins with a spreading rash at the site of the tick bite and is accompanied by fever, headache, extreme fatigue, aching joints and muscles and mild neck stiffness. If untreated, these symptoms usually resolve over several weeks but over subsequent weeks or months disorders of the nervous system, heart and joints may develop. Treatment works best early in the illness. Med attn shd be sought.

 Lyme is an infection caused by a corkscrew-shaped bacte- ria that is transmitted by the bite of deer (Ixodes scapularis) and western black-legged (Ixodes pacificus) ticks. The deer tick, which normally feeds on the white- footed mouse, the white-tailed deer, other mammals, and birds, is responsible for transmitting Lyme disease bacteria to humans in the NE and N.ctrl US. On the Pacific Coast, the bacteria are transmitted to humans by the western black-legged tick.
 The deer tick (Ixodes scapularis) adult female, adult male, nymph, and larva on a centimeter scale. much smaller than common dog and cattle ticks. In their larval and nymphal stages, they are no bigger than a pinhead. Adult ticks are slightly larger. Ticks feed on blood by inserting their mouth parts (not their whole bodies) into the skin of a host animal. They are slow feeders: a complete blood meal can take several days. As they feed, their bodies slowly enlarge.
 The number of annually reported cases of Lyme disease in the US has increased about 25-fold since national survei- llance began in 1982, and a mean of approximately 12,500 cases annually were reported by states to CDC from 1993-1997. In the US, the disease is mostly localized to states in the NE, mid-Atlantic, and upper north-central regions, and to several counties in NW California.
 Most B. burgdorferi infections are thought to result from periresidential exposure to infected ticks during prop- erty maintenance, recreation, and leisure activities. Thus, individuals who live or work in residential areas surrounded by woods or overgrown brush infested by vector ticks are at risk of getting Lyme disease.

In addition, persons who participate in recreational activities away from home such as hiking, camping, fishing and hunting in tick habitat, and persons who engage in outdoor occupa- tions, such as landscaping, brush clearing, forestry, and wildlife and parks management in endemic areas may also be at risk of getting Lyme disease.

 Lyme disease is a tick-transmitted infection which may be acquired throughout North America, Europe and Asia. The illness usually begins with a spreading rash at the site of the tick bite and is accompanied by fever, headache, extreme fatigue, aching joints and muscles and mild neck stiffness. If untreated, these symptoms usually resolve over several weeks but over subsequent weeks or months disorders of the nervous system, heart and joints may develop. Treatment works best early in the illness. Medical help should be sought.

- Lyme Disease Is Hard to Catch and Easy to Halt, Study Finds By GINA KOLATA Jun 13, 2001 

Lyme disease is very difficult to catch, even from a deer tick in a Lyme-infested area, and can easily be stopped in its tracks with a single dose of an antibiotic, a new study shows.

And two other studies conclude that prolonged and intensive treatment with antibiotics, a course of care advocated by a small group of doctors, does nothing for people with symptoms often attributed to chronic Lyme disease. These findings are in keeping with the assertions of researchers who say that in most cases, such symptoms have nothing at all to do with the disorder.

The three studies, scheduled to be published on July 12 in The New England Journal of Medicine, were released yesterday because the journal's editors thought they were so important, with the onset of summer and the accompanying fear of Lyme disease. "This is reassuring information for people who make decisions based on evidence," said Dr. Jeffrey M. Drazen, the journal's editor in chief. 

Researchers, both those associated with the studies and others who were not, said they hoped the findings would ease what they called inflated public fear of Lyme disease, which is widely perceived as a grave illness that is easy to catch. A total of 16,019 cases were reported to the Centers for Disease Control and Prevention in 1999; 92 percent of those cases were in nine states, most of which are in the Northeast, including New York and Connecticut.

Dr. Leonard H. Sigal, a Lyme disease expert at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical Center in New Brunswick, who was not associated with the studies, said the message from them was that "Lyme disease, although a problem, is not nearly as big a problem as most people think."

"The bigger epidemic," Dr. Sigal said, "is Lyme anxiety."

The study to see whether a single dose of the antibiotic doxycycline could prevent Lyme disease was directed by Dr. Robert B. Nadelman, a professor of medicine at New York Medical College and attending physician at the Westchester Medical Center, both in Valhalla, N.Y. 

Dr. Nadelman said many doctors, in hopes of heading off Lyme disease infection, had been giving 10-to-21- day courses of the antibiotic to people who had found deer ticks on their bodies.

"They would be treating people as if they actually had the disease," he said.

He and his colleagues wondered whether one dose would be enough. They recruited 482 people in Westchester County, N.Y., where the incidence of Lyme disease is among the highest in the world. All had found deer ticks on their bodies. (The insects were identified by entomologists.)

Half got a single dose of doxycycline, taken in the form of two capsules, and the others got two dummy capsules. The investigators found that the drug did prevent Lyme disease: just one person, 0.4 percent of those who took it, came down with the illness. But even among those who took the placebo, the chances of getting the disease was just 3 percent. 

Dr. Eugene Shapiro of Yale University School of Medicine, who wrote an accompanying editorial, noted that the antibiotic often caused nausea, vomiting and abdominal pain and that among those who took it, there would have been very little chance of getting Lyme disease in any case. People who are bitten can watch the site where the tick fed, Dr. Shapiro said, and if they develop a rash within a few weeks, they can take a full course of antibiotics. 

"Give that person 10 to 21 days of antibiotics," he said, "and they will be fine." Dr. Sigal agreed. He added that deer ticks crawl around the body for hours before settling down to feed, and during that time are easily washed off with a washcloth. And, he said, "even if you get the disease, it is easily treatable and it is curable." 

But Dr. Jesse L. Goodman, a Lyme disease expert at the University of Minnesota, said some people were so horrified by the possibility of getting Lyme disease that even a 3 percent risk was too much for them. "As a physician, I could respect that," Dr. Goodman said, adding that he would offer those people doxycycline. 

Lyme disease researchers emphasized, however, that previous studies had shown that most people with the infection get better on their own, without antibiotics. And while a small percentage develop serious symptoms, like arthritis or heart disorders, even the vast majority of these get better, the researchers said.

Dr. Raymond Dattwyler, director of the Lyme Disease Center at the State University of New York at Stony Brook, said the typical Lyme disease patient has a rash but no other symptoms, takes an antibiotic and is cured.

The two other studies released yesterday, financed by the National Institutes of Health, addressed the question of how to treat people who had Lyme disease and later developed symptoms like fatigue, aches and pains, and memory loss. Both were conducted by Dr. Mark S. Klempner of Boston University School of Medicine and his colleagues.

One study enrolled patients who had antibodies to the Lyme disease microorganism, Borrelia burgdorferi, an indicator that they had been infected. The other enrolled patients who no longer had antibodies but had had a documented case of Lyme disease. Half the patients in both studies received an intravenous antibiotic, ceftriaxone, for a month, followed by oral doxycycline for 60 days; the others received dummy medications. The question was, Would this intensive antibiotic treatment make the patients better?

The studies were meant to enroll 260 patients, but they ended early, after enrolling just 129 patients, because an independent committee overseeing them said it had become clear that the antibiotics were no more effective than the placebos. 

Dr. Shapiro said he was not surprised. Although a small group of doctors and patients insist that symptoms like fatigue and memory loss after a bout with Lyme disease are due to chronic infection with the disease organism, those symptoms are very common among the general public, leading Dr. Shapiro and others to believe there is some other cause.

"Whatever is going on with these patients," he said, "if it is unresponsive to antibiotics, it is unlikely that it is untreated Lyme disease." In contrast, antibiotics have been shown to work extraordinarily well when, for instance, the Lyme organism has demonstrably infected the brain, Dr. Dattwyler said. 

But some who have treated hundreds of patients with long-term antibiotics, like Dr. Sam L. Donta of Boston University Medical Center, were not convinced. The antibiotics in the studies were not given for a long enough time, Dr. Donta said, and he would have chosen different ones. Perhaps all that the studies show, he said, is "that this particular treatment doesn't work." 

Dr. Brian Fallon, an associate professor of psychiatry at Columbia University, is directing another study of chronic Lyme disease that focuses on patients who have problems with fatigue, their memory and their ability to think. In his study, also supported by the National Institutes of Health, the patients receive intravenous antibiotics for 10 weeks, or a placebo. 

Dr. Fallon said he saw many such patients in his private practice and would continue to refer them to colleagues for long-term treatment with intravenous antibiotics. 

Dr. Sigal said, however, that in addition to the expense of long-term intravenous antibiotics — and some patients end up taking them for years — the drugs are dangerous. Some patients have died of infections caused by the catheters in their bodies, and others have experienced side effects from the drugs, including destruction of bone marrow, requiring a bone marrow transplant.

"These are not benign drugs — they're all poisons," Dr. Sigal said. When they are needed to fight an infection, their risks, of course, are outweighed by their benefits. But when there are no benefits, he added, the risks are naturally unacceptable. 

-- Lyme Disease Drops, Especially in Areas Near NY City By WINNIE HU

WHITE PLAINS, Jan 9 01 — Reported cases of the tick-borne Lyme disease dropped last year in Westchester, Suffolk, Nassau and Dutchess Counties but increased in New York City and other parts of the state, according to preliminary statistics released today by state and city health officials. 

There were 4,310 Lyme disease cases reported among NY residents in 2000, down 2.6% from 1999. But the drop was much steeper in several suburban areas in which ticks have infected many residents in recent years.

In Westchester, there were 272 reported cases of Lyme disease, down 50.8 percent from 553 cases in 1999. Suffolk had a 33.1 percent decrease, to 567 cases last year, from 847. The largest number of Lyme disease cases was reported in Dutchess County. Even so, the 1,059 reported cases represented a 23.5 percent decrease from 1999.

But these decreases appeared to be largely offset by increases in Putnam, Orange, Columbia, Greene and other counties — another sign that Lyme disease has gradually spread from Long Island and Westchester to the Hudson River Valley in the last two decades. In Columbia County, south of Albany, there were 591 reported cases last year, up from 394 cases in 1999. 

And in NY City, which keeps its own stats for Lyme disease, there also seemed to be an increase, with 268 reptd cases last year, though that number may change as city health officials confirm those cases in the next year. There were 157 confirmed cases in 1999, according to city officials.

Dr. Dennis White, director of the arthropod-borne disease program for the State Dept of Health, cautioned against reading too much into the stats. He said the numbers tended to fluctuate by 10-15% depending on many variables, like the weather and the tick population.

In New Jersey and Connecticut, complete stats for Lyme disease in 2000 were not yet available. There were 1,603 reported cases of Lyme disease in NJ as of Dec 20, down from 1,719 cases in all of 1999.

Several scientists and state officials attributed the decline in part to the cool, wet weather that kept more people indoors last summer. Others said it may have resulted, at least in part, from efforts to educate residents about the dangers of the mosquito-borne West Nile virus. In 1984, Westchester became the first county in the country to declare Lyme disease a public health threat, county officials say.

- Tick and Flea Myths -- Myth> Ticks, not fleas, feed on blood. Fact> Fleas are blood-sucking parasites.

Myth> Fleas only feed on dogs and cats. Fact> Unlike lice, fleas are highly mobile and often not particular about what species they visit. In the absence of a pet, for exam, humans become the flea's blood meal.

Myth Fleas die quickly unless attached to a food source. Fact> Adult fleas can survive w/o food for a long time.

Myth> The most common household flea is the dog flea. Fact> The cat flea is the most common household flea - even on dogs.

Myth> Fleas can only survive in warm climates or during warm summer months. Fact> Fleas can reproduce rapidly at room temperature, making your home an ideal year-round environment.


\9 Malaria

This serious and potentially fatal disease is spread by mosquito bites. If travelling in endemic areas it is extremely important to avoid mosquito bites and to take tablets to prevent this disease. Symptoms range from fever, chills and sweating, headache, diarrhoea and abdominal pains to a vague feeling of ill-health. Seek medical help immediately if malaria is suspected.   Without treatment malaria can rapidly become more serious and can be fatal. If medical care is not available, malaria tablets can be used for treatment. You need to use a malaria tablet which is different to the one you were taking when you contracted malaria. The treatment  dosages are mefloquine (two 250mg tablets and a further two six  hours later), fansidar (single dose of three tablets). If you were  previously taking mefloquine then other alternatives are  halofantrine (three doses of two 250mg tablets every six hours) or  quinine sulphate (600mg every six hours). There is a greater risk of  side effects with these dosages than in normal use. Travellers are advised to prevent mosquito bites at all times. The  main messages are: - Wear light coloured clothing - Wear long pants and long sleeved shirts - Use mosquito repellents containing the compound DEET on exposed - areas (prolonged overuse of DEET may be harmful, especially to - children, but its use is considered preferable to being bitten by disease-transmitting mosquitoes) Avoid highly scented perfumes or aftershave. Use a mosquito net impregnated with mosquito repellent (permethrin) - it may be worth taking your own Impregnating clothes with permethrin effectively deters mosquitoes and other insects

Over 300 million people develop clinical cases of malaria each year, and one to three million of them die. Many of these are children living in subsaharan Africa. Almost half of the world's population lives in an area where they are at risk of contracting the disease. Malaria is caused by protozoa of genus Plasmodium. Each of the four species of malaria parasite that infect man causes a somewhat different form of the disease. Malaria caused by P. falciparum is the most dangerous form and accounts for the overwhelming majority of deaths. Unless appropriately treated, it can produce several life-threatening complications including kidney failure and coma.
  The parasites are transmitted to humans by female anopheline mosquitoes. When the mosquito takes a blood meal on the host, she injects the parasites along with her saliva. The parasites develop first in liver cells and then infect red blood cells (erythrocytes), where they consume hemoglobin, the oxygen-carrying  component of the blood. The parasites divide in the red cell, and at the completion of development the red cell ruptures releasing parasites that can infect many other erythrocytes. The typical symptoms of malaria, cycles of chills, fever and sweating, are experienced by patients at these times.
  In 1955, the World Health Organization began an extensive campaign, using insecticides and drugs, to eradicate malaria. Despite a number of dramatic successes, the objective proved elusive. Mosquitoes not only modified their behavior to avoid coming into contact with insecticides, but actually developed resistance to these chemicals. Parasites also became resistant to the widely used drug chloroquine and other antimalarials. Mounting evidence shows that malaria is once again gaining the upper hand. Areas that have been free of malaria have been experiencing outbreaks, and the number of cases have been rising alarmingly in the Amazon and parts of Asia, especially Southeast Asia. In Africa, malaria has been moving from rural areas to the cities.
  At one time, malaria was a serious health problem in the U.S.; in 1914 more than 600,000 cases of malaria occurred here. Although improved public health led to a substan- tial decline in the following decades, minor resurgences have occurred as troops returned from both the Korean and Vietnam wars. 

In 1995, approx 1200 cases of malaria were reported to the U.S. CDC. Not all of these cases were "imported"; several were recent infections acquired within the U.S. following the bite of indigenous mosquitoes. Recently, cases of locally transmitted malaria have been appearing in regions as diverse as CA, FL, NJ, NY, TX and MI.

Malaria Info for Travelers to SE Asia - Brunei Darussalam, Burma (Myanmar), Cambodia, East Timor, Indonesia, Lao People's Democratic Republic (Laos), Malaysia, Philippines, Singapore, Thailand, Vietnam.

Transmission and Symptoms Malaria is a serious disease transmitted to humans by the bite of an infected female Anopheles mosquito. Symptoms may include fever and flu-like illness, including chills, headache, muscee aches, and fatigue. Malaria may cause anemia and jaundice. P. falciparum infections, if not promptly treated, may cause kidney failure, coma, and death. Malaria can often be prevented by using antimalarial drugs and by using personal protection measures to prevent mosquito bites. However, in spite of all protective measures, travelers may still develop malaria. Malaria symptoms will occur at least 7 to 9 days after being bitten by an infected mosquito. Fever in the first week of travel in a malaria-risk area is unlikely to be malaria; however, any fever should be promptly evaluated.

 Travelers who become ill with a fever or flu-like illness while traveling in a malaria-risk area and up to 1 year after returning home should seek prompt medical attention and should tell the physician their travel history.

Malaria Risk by Country Brunei Darussalam: No risk. Burma (Myanmar): Rural only. No risk in cities of Rangoon (Yangon) and Mandalay. Special note: Travelers to the eastern states of Burma (Shan, Kayah, Kayin) should use either doxycycline or Malarone™ as their antimalarial drug because of mefloquine-resistant Plasmodium falciparum in that area.

Cambodia: All, except no risk in Phnom Penh. Risk exists at the temple complex at Angkor Wat. Special note: Travelers to the western provinces bordering Thailand should use either doxycycline or Malarone™ as their antimalarial drug, because of mefloquine- resistant Plasmodium falciparum in the area.

East Timor: All areas. Indonesia: Rural areas only, except high risk in all areas of Irian Jaya (western half of island of New Guinea). No risk in cities in Java and Sumatra and no risk in the main resort areas of Java and Bali. Risk exists at the temple complex of Borobudur.

 Lao People's Democratic Republic (Laos): All, except no risk in city of Vientiane. 

Malaysia: remote areas of peninsular Malaysia and Sarawak (NW Borneo). Urban and coastal areas are risk free. Sabah (NE Borneo) has risk throughout.

 Philippines: Rural only, except no risk in the provinces of Bohol, Catanduanes, Cebu, and metropolitan Manila. Subic Bay is a risk area.

 Singapore: No risk.

 Thailand: Limited risk in the areas that border Cambodia, Laos, and Burma. No risk in cities and major tourist resorts (Bangkok, Chiang Mai, Chiang Rai, Pattaya, Phuket Island, and Ko Samui.) Special note: Travelers to the border areas should take either doxycycline or Malarone™ as their antimalarial drug because of mefloquine-resistant Plasmodium falciparum in the area.

Vietnam: Rural areas, except no risk in the Red River Delta and the coastal plains north of Nha Trang.

 Prevention Travelers to the risk areas listed below should take one of the following drugs: mefloquine (Lariam®), doxycycline, or Malarone™: Burma (Myanmar) (Travelers to the eastern states [Shan, Kayah, Kayin] should take either doxycycline or Malarone.)  Cambodia (Travelers to the western provinces bordering Thailand should take either doxycycline or Malarone.)  East Timor  Indonesia  Laos  Malaysia  Vietnam  Philippines, in the following provinces: Luzon, Basilian, Mindoro, Palawan, Mindanao, and the Sulu Archipelago (Travelers to other provinces should take chloroquine; see below.)

Mefloquine (brand name Lariam®) Directions for use The adult dosage is 250 mg salt (one tablet) once a week.  Take the first dose of mefloquine 1 week before arrival in the malaria-risk area.  Take mefloquine once a week, on the same day of the week, while in the malaria-risk area.  Take mefloquine once a week for 4 weeks after leaving the malaria-risk area.  Mefloquine should be taken on a full stomach, for example, after dinner.  Mefloquine side effects Most travelers who take mefloquine have few, if any, side effects. The most commonly reported minor side effects include nausea, dizziness, difficulty sleeping, and vivid dreams. Mefloquine has very rarely been reported to cause serious side effects, such as seizures, hallucinations, and severe anxiety. Minor side effects usually do not require stopping the drug. Travelers who have serious side effects should see a health care provider. Do NOT take mefloquine if you have Ever had an allergic reaction to mefloquine;  Epilepsy or other seizure disorders;  A history of severe mental illness or other psychiatric disorders;  Been diagnosed or treated for an irregular heartbeat.

Alternatives for travelers who cannot or choose not to take mefloquine include doxycycline or Malarone™. Travelers to the following areas should take either doxycycline or Malarone™: Cambodia: western provinces bordering Thailand.  Thailand: areas bordering Cambodia and Burma (Myanmar).  Burma (Myanmar): eastern states of Shan, Kayah, Kayin.  Mefloquine would not be recommended in these areas because of mefloquine-resistant Plasmodium falciparum.

Doxycycline Directions for use The adult dosage is 100 mg once a day.  Take the first dose of doxycycline 1 or 2 days before arrival in the malaria-risk area.  Take doxycycline once a day, at the same time each day, while in the malaria-risk area.  Take doxycycline once a day for 4 weeks after leaving the malaria-risk area.

Doxycycline side effects and warnings Taking doxycycline may cause travelers to sunburn faster than normal. To prevent sunburn, avoid midday sun, wear a high-SPF sunblock, wear long-sleeved shirts, long pants, and a hat.  Take doxycycline on a full stomach to lessen nausea; do not lie down for 1 hour after taking the drug to prevent reflux of the drug (backing up into the esophagus).  Women who use doxycycline may develop a vaginal yeast infection. Take an over-the-counter yeast medication with you on your trip for use if vaginal itching or discharge develops.

Do NOT take doxycycline if you are pregnant. Do NOT give doxycycline to children under the age of 8; teeth may become permanently stained. Alternatives for travelers who cannot or choose not to take doxycycline include mefloquine or Malarone™.

Malarone™ Malarone is a new antimalarial drug in the US. Malarone is a combination of two drugs (atovaquone and proguanil) and is an effective alternative for travelers who cannot or choose not to take doxycycline or mefloquine.

Directions for use The adult dosage is 1 adult tablet (250 mg atovaquone/100 mg proguanil) once a day.  Take the first dose of Malarone 1 to 2 days before travel to the malaria-risk area.  Take Malarone once a day during travel in the malaria-risk area.  Take Malarone once a day for 7 days after leaving the malaria-risk area.  Take the dose at the same time each day with food or milk.

Malarone Side Effects and Warnings Although side effects are rare, abdominal pain, nausea, vomiting, and headache can occur. Malarone should not be taken by patients with severe renal impairment. Pregnant women or women breast-feeding infants weighing less than 11 kg (24 lbs) should not take Malarone to prevent malaria.

Chloroquine (brand name Aralen®) is the recommended drug for travelers to risk areas in: Philippines (Travelers to Basilian, Luzon, Mindanao, Mindoro, Palawan, and the Sulu Archipelago should take either mefloquine, doxycycline, or Malarone as their antimalarial drug.)

Directions for use The adult dosage is 500 mg (salt) chloroquine phosphate once a week.  Take the first dose of chloroquine 1 week before arrival in the malaria-risk area.  Take chloroquine once a week, on the same day of the week, while in the malaria-risk area.  Take chloroquine once a week for 4 weeks after leaving the malaria-risk area.  Chloroquine should be taken on a full stomach to lessen nausea.

Chloroquine side effects Although side effects are rare, nausea and vomiting, headache, dizziness, blurred vision, and itching can occur. Chloroquine may worsen the symptoms of psoriasis.

Preventing Insect Bites Protect yourself from mosquito bites. Prevent mosquito bites by wearing long-sleeved shirts and long pants; apply insect repellent to exposed skin. Mosquitoes that transmit malaria bite between dusk and dawn. Use insect repellents that contain DEET. When using repellent with DEET, follow these precautions: Always use according to label directions.  Use only when outdoors and wash skin after coming indoors.  Do not breathe in, swallow, or get into the eyes.  Do not put on wounds or broken skin.  Use a concentration of 30% to 35%.

Travelers who will not be staying in well-screened or air-conditioned rooms should use a pyrethroid-containing flying-insect spray in living and sleeping areas during evening and nighttime hours. In addition, travelers should take additional precautions, including sleeping under mosquito netting (bed nets). Bed nets sprayed with the insecticide permethrin are more effective. In the United States, permethrin is available as a spray or liquid to treat clothes and bed nets. Bed nets may be purchased that have already been treated with permethrin. Permethrin or another insecticide, deltamethrin, may be purchased overseas to treat nets and clothes.

Malaria: General Info, What is malaria? Malaria is a serious, sometimes fatal, disease caused by a parasite. There are four kinds of malaria that can infect humans: Plasmodium falciparum (plaz-MO-dee-um fal-SIP-a-rum), P. vivax (VI-vacks), P. ovale (o-VOL-ley), and P. malariae (ma-LER-ee-aa). Where does malaria occur? Malaria occurs in over 100 countries and territories. More than 40% of the people in the world are at risk. Large areas of Central and South America, Hispaniola (Haiti and the Dominican Republic), 

Africa, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania are considered malaria-risk areas (an area of the world that has malaria). 

How common is malaria? The World Health Organization estimates that yearly 300-500 million cases of malaria occur and more than 1 million people die of malaria. About 1,200 cases of malaria are diagnosed in the United States each year. Most cases in the United States are in immigrants and travelers returning from malaria-risk areas, mostly from sub-Saharan Africa and the Indian subcontinent.

 How do you get malaria? Humans get malaria from the bite of a malaria-infected mosquito. When a mosquito bites an infected person, it ingests microscopic malaria parasites found in the person’s blood. The malaria parasite must grow in the mosquito for a week or more before infection can be passed to another person. If, after a week, the mosquito then bites another person, the parasites go from the mosquito’s mouth into the person’s blood. The parasites then travel to the person’s liver, enter the liver’s cells, grow and multiply. During this time when the parasites are in the liver, the person has not yet felt sick. The parasites leave the liver and enter red blood cells; this may take as little as 8 days or as many as several months. Once inside the red blood cells, the parasites grow and multiply. The red blood cells burst, freeing the parasites to attack other red blood cells. Toxins from the parasite are also released into the blood, making the person feel sick. If a mosquito bites this person while the parasites are in his or her blood, it will ingest the tiny parasites. After a week or more, the mosquito can infect another person. Each year in the United States, a few cases of malaria result from blood transfusions, are passed from mother to fetus during pregnancy, or are transmitted by locally infected mosquitoes.

 What are the signs and symptoms of malaria? Symptoms of malaria include fever and flu-like illness, including shaking chills, headache, muscle aches, and tiredness. Nausea, vomiting, and diarrhea may also occur. Malaria may cause anemia and jaundice (yellow coloring of the skin and eyes) because of the loss of red blood cells. Infection with one type of malaria, P. falciparum, if not promptly treated, may cause kidney failure, seizures, mental confusion, coma, and death.

 How soon will a person feel sick after being bitten by an infected mosquito? For most people, symptoms begin 10 days to 4 weeks after infection, although a person may feel ill as early as 8 days or up to 1 year later. Two kinds of malaria, P. vivax and P. ovale, can relapse; some parasites can rest in the liver for several months up to 4 years after a person is bitten by an infected mosquito . When these parasites come out of hibernation and begin invading red blood cells, the person will become sick.

 How is malaria diagnosed? Malaria is diagnosed by looking for the parasites in a drop of blood. Blood will be put onto a microscope slide and stained so that the parasites will be visible under a microscope.

 Any traveler who becomes ill with a fever or flu-like illness while traveling and up to 1 year after returning home should immediately seek professional medical care. You should tell your health care provider that you have been traveling in a malaria-risk area. Who is at risk for malaria? Persons living in, and travelers to, any area of the world where malaria is transmitted may become infected.

 What is the treatment for malaria? Malaria can be cured with prescription drugs. The type of drugs and length of treatment depend on which kind of malaria is diagnosed, where the patient was infected, the age of the patient, and how severely ill the patient was at start of treatment.

 How can malaria and other travel-related illnesses be prevented? Visit your health care provider 4-6 weeks before foreign travel for any necessary vaccinations and a prescription for an antimalarial drug.  Take your antimalarial drug exactly on schedule without missing doses.  Prevent mosquito and other insect bites. Use DEET insect repellent on exposed skin and flying insect spray in the room where you sleep.  Wear long pants and long-sleeved shirts, especially from dusk to dawn. This is the time when mosquitoes that spread malaria bite.  Sleep under a mosquito bednet that has been dipped in permethrin insecticide if you are not living in screened or air-conditioned housing


\10 Meningitis - bacterial

Meningococcal Disease is an infection of the fluid of a person's spinal cord and the fluid that surrounds the brain. People sometimes refer to it as spinal meningitis. Meningitis is usually caused by a viral or bacterial infection. Knowing whether meningitis is caused by a virus or bacterium is important because the severity of illness and the treatment differ. Viral meningitis is generally less severe and resolves without specific treatment, while bacterial meningitis can be quite severe and may result in brain damage, hearing loss, or learning disability.

For bacterial meningitis, it is also important to know which type of bacteria is causing the meningitis because antibiotics can prevent some types from spreading and infecting other people. Before the 1990s, Haemophilus influenzae type b (Hib) was the leading cause of bacterial meningitis, but new vaccines being given to all children as part of routine immunizations have reduced the occurrence of invasive disease due to H. influenzae. Today, Streptococcus pneumoniae and Neisseria meningiti- dis are the leading causes of bacterial meningitis.

What are the signs and symptoms of meningitis?High fever, headache, and stiff neck are common symptoms of meningitis in anyone over the age of 2 years. These symptoms can develop over several hours, or they may take 1 to 2 days. Other symptoms may include nausea, vomiting, discomfort looking into bright lights, confusion, and sleepiness. In newborns and small infants, the classic symptoms of fever, headache, and neck stiffness may be absent or difficult to detect, and the infant may only appear slow or inactive, or be irritable, have vomiting, or be feeding poorly. As the disease progresses, patients of any age may have seizures.

This serious disease attacks the brain and can be fatal. There are recurring epidemics are Sub-Saharan Africa, Mongolia, Vietnam, the Amazon, northern India and Nepal.

A fever, severe headache, sensitivity to light and neck stiffness which prevents forward bending of the head are the first symptoms. There may also be purple patches on the skin. Death can occur within a few hours, so URGENT medical treatment is required IMMEDIATELY.

Trekkers to rural areas of NEPAL should be careful and aware, as the disease is spread by close contact with people who carry it in their throats and noses, spread it through coughs and sneezes and may not be aware that they are carriers. Lodges in the hills where travellers spend the night are prime spots for the spread of infection. Treatment is with large doses of penicillin given intravenously, or chloramphenicol injections.

 Meningitis Symptoms in adults - These symptoms may not all occur at the same time. Vomiting, Headache, Drowsi- ness, Seizures, High Temp, Joint Aching/Pain, Stiff Neck, Dislike of Light. (Septicemia may occur in adults and (Children.)

Some bacteria that cause meningitis can also cause Septicemia (also known as blood poisoning.)Septicemia can develop VERY QUICKLY - so be alert.The spots do not turn white when pressed !!The rash must be taken SERIOUSLY - CALL A DOCTOR IMMEDIATELY! 

Meningitis at a Glance Whether transmitted by a virus or bacteria, this brain inflammation spells danger. Dr. Bill & Martha Sears Adapted from the The Baby Book: CD-ROM Version Cause Bacteria or virus (incubation period depends on infectious agent, usually 10-14 days) Signs and Symptoms Bacterial (spinal meningitis): cold or flu symptoms; child increasingly ill; high fever; increasing lethargy, drowsiness, vomiting; stiff neck or legs; bulging fontanel; looks sick. Viral : baby usually does not rapidly become sicker Home Treatment Suspect if child getting quickly worse: more drowsy, doesn’t want to move, difficulty breaking fever, difficult to arouse; call doctor immediately Medical Treatment HIB vaccine lowers risk. Bacterial : spinal tap to confirm diagnosis; intravenous fluidsOf Special Note The earlier diagnosis and treatment, the better the outcome; also depends on type of germ. Suspect if child has cold or ear infection but is getting steadily more lethargic and fever doesn’t budge with treatment 

HEALTH WARNING If you believe that you have the illness you MUST CONTACT A PHYSICIAN AS SOON AS POSSIBLE. FAILURE TO DO SO COULD PROVE FATAL! Meningitis Can Kill Anyone, Anytime, Anyplace, Anywhere! 

BE ALERT! PROMPT ACTION SAVES LIVES

Treatment: YOUR LOCAL HOSPITAL!Time is more valuable than that perfect, well known specialist, half way across the country! Meningitis is an infection of the fluid and lining of the brain. In blood, infection is fought off by white blood cells. In the spinal fluid, there are no white blood cells...and there is nothing there to fight off infection. Once the infection starts, it can spread VERY RAPIDLY THROUGOUT THE BODY. 

This means you DO NOT have time to book a flight half way across the country for treatment. Meningitis can cause a great deal of brain damage in just a few hours, and can kill in 24 hours.The best advice is to go immediately to a local hospital with an infectious disease specialist. Once the infection is brought under control, you will have lots of time to deal with a plan for treatment of the residual effects. Many times a local hospital will transfer a seriously ill meningitis patient to the nearest university medical center.

Sometimes Rifampin is given (in meningococcal bacterial meningitis cases) as a preventative measure to roomates, close family members, or others who may have come in contact with an infected person.Here is a discussion of what drugs are typically used to treat meningitis. For information on over 7,000 different drugs click hereMENOMUNE is a vaccine against type meningococcal types A, C, Y, and W-135. There are also promising new treatments on the horizon for Viral meningitis.

PreventionMeningococcal meningitis has several strains - A, B C, Y, and W135. No vaccine exists for all of them, but MENOMUNE is a vaccine that protects against A,C,Y and W135. Vaccination is sometimes recommended for travelers to Africa and other high risk areas. Vaccination is also recommended for college freshmen who live in dormitories. We suggest that all young adults, 18-22 years of age be vaccinated. If you are having trouble finding MENOMUNE, have your doctor call 1-800-VACCINE for more information. Several trials are being conducted with vaccines against Group B.If someone becomes ill with the A or C strain, household and very close contacts of the patient should be offered the vaccine. It is not very effective in young children and protection for adults only lasts three to five years. 

Pneumococcal: Prevnar is a new vaccine that has recently been approved for prevention of pneumococcal diseases, including meningitis. 

Haemophilus influenza type b (Hib)A vaccine against Hib has formed part of the routine immunization program of American children since 1985. It is given in three doses, at two, three and four months at the same time as the diphtheria, tetanus and polio immunizations. The vaccine also protects against other severe infections caused by the Hib bacteria, such as epiglottis, cellulitis and septic arthritis. As a result of the immunization, Hib meningitis cases have fallen dramatically by around 95%. The vaccine does not protect against any other forms of meningitis
 Apart from vaccines, there is no known way to protect against meningitis. However, it is not highly infectious and only the patients close family contacts are at any significant risk of becoming ill. With meningococcal meningitis and sometimes with Hib, antibiotics are offered to these contacts. Other contacts, like schoolfriends or colleagues, are rarely at higher risk so do not normally need treatment. 
 Awareness of the symptoms and signs of meningitis, especially the rash which may accompany meningococcal meningitis is very important.
 Research indicates that passive smoking in the household setting can increase the chances of someone contracting meningitis. 
 Top 20 Meningitis FAQsThese are some of the most common questions asked concerning Meningitis. Many people such as students, journalists and interested members of the public are often looking to learn more about this disease.
 The simple message about the disease is - Meningitis Can Strike Anyone In Anyplace At Anytime. Being aware of the various aspects of the disease CAN mean that if the right actions are taken quickly, lives can be saved.
 1. What exactly in meningitis?Meningitis is inflammation of the meninges, the lining which surrounds the brain. The disease should not be confused with encephalitis which is inflammation of the brain itself.

2. How many types of meningitis are there?Essentially, there are two distinct types of meningitis; viral (caused by a virus) and bacterial (caused by a bacteria). Bacterial meningitis, whilst it is comparatively rare, is by far the most dangerous and is sometimes fatal. As such, it gets the most media attention but the Foundation is acutely aware of the effects of the more common viral meningitis.
 3. Just how common is each type? We do not have exact figures for America (this is an early aim of ours) as it is not a requirement of individual States to advise the CDC (Center for Disease Control) of meningitis cases they have each year. The figures published by the CDC for 1994 which shows a total of 12,992 cases reported to them. It is fatal in about 10% of cases. Viral meningitis is much more common but it is impossible to quote accurate figures because many mild cases may not even be reported by the sufferer to his/her doctor. 
 4. What causes Meningitis?The bacteria which cause bacterial meningitis live in the back of the nose and throat region and are carried at any given time by between 10% and 25% of the population. It causes meningitis when it gets into the bloodstream and travels to the meninges. What triggers this movement in a small number of unfortunate people remains the subject of research. With viral meningitis, the viruses responsible can be picked up through poor hygiene or polluted water

5. How are the bacteria and virus spread? Both are spread by coughing, sneezing and kissing but they should not be regarded as either water-borne or air-borne. It is a mistake to assume that the viruses and bacteria can be blown in the wind and float in water because they CANNOT live for very long outside the human body. Also see question 4 above.
 6. Can anyone get meningitis?Yes, although research shows that certain age groups are more susceptible than others. These are the under 5's, the 16-25's and the over-55's.
 7. Is meningitis seasonal?Either form can occur at ANY time but elsewhere in the world there is a pattern which shows that bacterial meningitis occurs more in the winter months (November-March inclusive) while viral meningitis sees most cases occurring during the summer months.
 8. What are the after effects of meningitis?With both forms there will be a wide variation in exactly how the disease effects a sufferer in the long term. Tiredness, recurring headaches, short-term memory difficulties and concentration problems are often reported, as are temper tantrums, forgetting recently-learned skills and babyish behavior in children.
 Mood swings, aggression, balance problems and clumsiness can all make daily life difficult both for the sufferer and his/her family and friends but these should pass in time.Deafness (permanent or temporary) is a more serious outcome, while epilepsy/seizures, sight problems and brain damage have been known but are relatively rare.
 9. What are the main symptoms?Again, with both forms there is a wide range which can onset in different 'combinations'. In adults and older children vomiting, high temperature, severe headaches, neck stiffness, a dislike of bright lights, drowsiness, other joint pains and fits may be present. In babies and infants watch for fever with hands and feet feeling cold, vomiting, refusing feeds, high pitched crying, a dislike of handling, neck retraction, a staring expression, difficulty in waking and a pale or blotchy complexion.

10. Isn't there a rash to watch for too?Yes, and it is VERY important. It can occur in anyone of ANY age and can begin on ANY part of the body. It looks like small clusters of tiny pin pricks at the beginning, these quickly develop into areas of skin damage. They are purple in color and will NOT turn white when pressed.
 11. Why is the rash so important?The development of the rash in the way described in question 10 is a key indicator of septicemia (blood poisoning). If it is seen, it is ABSOLUTELY VITAL that the sufferer is taken to the nearest ER WITHOUT DELAY. Septicemia develops when the bacteria which causes meningitis multiples while it is in the bloodstream and if not treated quickly can be fatal or mean the loss of limbs or fingers/toes.
 12. Do all the symptoms appear at once?No. Some will appear while others may not appear at all. This can cause difficulties in diagnosing meningitis, complicated by the fact that many symptoms are like the common cold. However, over and above the symptoms themselves, it will become obvious to anyone close to the sufferer that he/she is becoming VERY ill VERY quickly.
 13. What should I do if I see anyone showing these symptoms?Act quickly. Firstly, describe the symptoms as accurately as possible to the doctor. If you cannot reach him/her or if they cannot come immediately, get the person to the nearest ER and be prepared to insist on immediate attention.
 14. Wouldn't it be quicker to by-pass the family doctor?We believe this is not advisable unless he cannot attend immediately. Diagnosing the form of meningitis is complicated and the family doctor is best person able to advise the right course of action. These days, he/she is much more likely to carry a supply of benzylpenicillin which can be administered to the sufferer immediately. This action can "buy valuable time" and should the case turn out to be the bacterial form, could make a major difference. Should the case ultimately turn out to be the viral form, no harm will have been done.

15. Is it true there are different types of bacterial meningitis?Yes, they are called strains and there are several worth mentioning; meningococcal, pneumococcal, Hib, TB and neonatal meningitis. TB and neonatal are very rare, and Hib (which almost exclusively affects under 4's) has become rarer since the introduction of a vaccine for all under 4's. More information on all these forms are available on this site. 
 16. So meningococcal and pneumococcal are the most common strains? Yes, pneumococcal meningitis tends to affect either young children, older people and anyone who has already had a chronic illness such as heart disease, liver disease or diabetes. Meningococcal is the most common strain and can be further sub-divided into three groups, commonly referred to as A, B, C. 
 17. What is the position on available vaccines?Firstly, as stated above, the Hib vaccine has been successfully introduced but it is important to point out that it is ONLY effective against the Hib strain. The under 4's REMAIN SUSCEPTIBLE to all the other strains. Currently there is one vaccine which combats both Group A and C meningococcal meningitis but it is not very effective in young children and of limited effectiveness in adults. There is no vaccine against the most common strain B.
 18. What of the future of vaccines?It is universally agreed that vaccine development is the route to take in fighting meningitis. Some new vaccines are currently being tested and the scientific community remain hopeful that further studies will be made in the next several years. While this research is highly complex, technological advances continue to be made. 
 19. Why do people fear meningitis?Because of the number of cases and the fact that very little has been explained to the public. Until the Meningitis Foundation of America began in 1997, the US had no national organization working in this area offering advice and support to the general public.We believe that the public and opinion-formers, such as the media, will become more aware of the facts in the months ahead. These are that meningitis cases are normally isolated and unconnected and that speed is of the essence if the disease is suspected.
 20. What would be your final message concerning meningitis?When fighting meningitis there are two sides involved; human beings who are by nature are all different and viruses/bacteria which are the most ancient organisms about which we have much to learn. As such, it is impossible to draft "golden rules" about any aspect of the disease. The only certainty is that there are - and will remain - many committed people, working internationally, who are devoted to its ultimate eradication and support for those who have suffered from it. 

Missed Diagnosis Far too often we hear stories of missed diagnosis or delayed diagnosis of meningitis. All too often, an early reaction of a parent of a pediatric patient is to take legal action. In some cases, this may be warranted, but first put yourself in the shoes of the physician that has seen 25 cases of high fever, ear infection, vomiting, etc today, and possibly every day for the last 15 years without seeing their first case of meningitis. Suddenly, WHAM, that one patient comes in...will the suggested treatment be the same?

The following is an extract of an article which appeared in the Medical Protection Society's "Casebook", and "Headlines" the newsletter of the National Meningitis Trust...our counterpart in the UK. We have obtained permission from the Society to reproduce it here. It was written by Professor A.G.M. Campbell, Emeritus Professor of Child Health at the University of Aberdeen and Dr. Frances Cranfield, a General Practitioner in Welwyn Garden City. Both are member of the Society. Although it makes some references to statistics, regulations, and practices that may apply to the UK but would not apply to the United States, it is still a VERY WORTHWHILE ARTICLE FOR MEDICAL PROFESSIONALS AS WELL AS THE PARENTS OF VICTIMS. We wish to thank Drs Campbell and Cranfield for their excellent article.

MENINGITIS UNTIL PROVEN OTHERWISE The vast majority of cases of meningitis first manifest themselves in general practice. The achievement of high levels of vaccination coverage against Hib has reduced invasive Hib infections in young children by over 95%. Meningococcus bacteria are therefore now the dominant ‘causative organism’. 

Pneumococcal meningitis, while less common, is particu- larly serious in young infants and tuberculosis mening- itis, while rare in the UK, figures disproportionately highly among cases of delayed diagnosis. 

Diagnosing Meningitis It is not surprising that there are difficulties with diagnosis. The presenting symptoms and signs, particularly in infants, can be subtle and confusing. The ability to distinguish the child with septicaemia/meningitis from the many others who present with febrile illness requires experience, good rapport with parents and a high index of suspicion. In other words, for early diagnosis there is not substitute for clinical acumen. Fever tends to be higher in bacterial meningitis (for example over 39 deg C) than in viral infections but infants may have a normal temperature or even hypothermic.

 No single symptom or sign is necessarily diagnostic – it is a clustering of features combined with the lack of any obvious focus for the infection that should raise suspicions. An apparently trivial respiratory tract infection is a frequent prodrome, followed by a worrisome change in the child’s normal pattern of behaviour – such as feeding, sleeping, playing and interest in surroundings. In infants, reluctance to feed, with unusual irritability alternating with periods of lethargy and drowsiness are particularly important. 

Helpful pointers to the diagnosis may be absent. For example, the anterior fontanelle may have closed and even if still open may not always "bulge", particularly if dehydration is present. Meningeal signs like neck stiffness may be absent in young children whilst the older child or adult may complain of a headache. Vomiting is frequent in all age groups. Children aged between six months and two years seem particularly prone to pneumococcal bacteriaemia with apparently unexplained fever and no localising symptoms or signs. A review of the cases in which the Society has provided assistance to its members indicated some problems which recur time and time again: 

Failure to visitNHS regulations state that the doctor should consider, in the light of the patient’s medical condition, whether a consultation is needed and if so, when. Thus a doctor does not always have to visit when requested but must make an informed decision as to whether a visit is necessary.

It is usually best to speak to the patient, or if that is not possible, to the parent, relative of friend who has been providing care. It is better to visit when requested than to refuse, and then to educate the patient if the visit was unnecessary. A perceived refusal to visit will make rapport with a family more difficult and will be remembered if things go wrong.

Failure to examine appropriatelyLarge numbers of children and adults present every day in general practice with febrile illness and it can be very difficult to identify the patient who may have early signs and symptoms of meningitis. Obviously one needs to take an adequate history and undertake an appropriate examination with the patient suitably undressed.

Failure to reach a reasoned diagnosisA General Practitioner is not always expected to be right, provided he has placed himself in a position to make an informed decision. In reaching a decision, he is not expected to exercise a higher degree of skill, knowledge, and care than may reasonably be expected, To illustrate, he would not be considered negligent in failing to diagnose tuberculosis meningitis but would be expected to realise that the patient was seriously ill and required further investigation and treatment.

Where the anticipated improvement to initial treatment has not occurred, it is always necessary to review one’s original diagnosis taking account of all available information. Considering the rare incidence of tuberculosis meningitis in the UK it is over represented in medical negligence, primarily due to the diagnosis being delayed until considerable neurological damage has occurred. This delay is frequently because early symptoms and signs may be particularly insidious and subtle. Some cases have been diagnosed only after considerable delay in hospital simply because of unfamiliarity with the CSF findings. Inconsistencies in the symptomatology and progress of viral versus bacterial meningitis, puzzling findings in the CDF and the patient’s lack of response to conventional antibiotic treatment should always raise the possibility of TBM. 

Sometimes it may be prudent to start a trial of anti-tuberculosis therapy while awaiting laboratory confirmation. TBM should always be considered when:Examination of the CSF reveals lymphcytes in association with a marked reduction in CSF glucose.Bacterial meningitis, thought to be ‘partially treated and no organism identified’ seems resistant to the usual antibiotics.‘viral meningitis’ is associated with focal neurological signs and continues to worsen instead of improving spontaneously.

Failure to arrange adequate follow upIt is important that when a doctor sees a patient either in the surgery or in the home, he fives all necessary advice concerning follow-up. Meningitis should always be considered if there is no obvious focus for a child’s persistent pyrexia. If a doctor thinks that an ill child is suffering from nothing more than a viral infection, immediate hospital referral is not necessary. However, arrangements must be made for adequate follow up. The parents should be given clear advice about reporting any worrying changes in the child’s condition. Such developments might include the development of a rash, changes in state of alertness or abnormal movements that might indicate seizure activity.

A diffuse maculopapular rash is frequently seen in viral illnesses but can also be an early manifestation of bacterial infection especially meningococcaemia. The rapidly-spreading purpuric rash said to be ‘diagnostic’ of this condition may follow within a few hours, but by this time the prognosis will be much worse.Meningococcal septicaemia – with or without meningitis – can progress to cardiovascular collapse and shock within a few hours. If a doctor thinks a child could have septicaemia with or without meningitis, the child should be referred to a hospital immediately. In short, the order of the day should be ‘meningitis until proved otherwise’.

Failure to refer or to give the necessary degree of urgencyThis is a frequent source of complaint. A doctor is required to exercise a reasonable level of professional judgement when making a decision whether or not to refer or to admit a patient.

Failure to keep adequate recordsFailure to keep proper records can of course have an impact on patient care. Some cases of missed diagnosis with meningitis have involved care given by several doctors where the notes have not adequately reflected the previous history and findings – thus contributing to the diagnostic failure. Sometimes claims become indefensible simply because the notes are inadequate or absent. A general practitioner may still be found in breach of terms of service if he or she does not keep manual notes even though there may be full computer records. One would not wish to encourage lengthy defensive not-keeping but, when a diagnosis of meningitis has been considered, it is wise to record negative findings, for example, that a check has been made for meningeal signs such as neck stiffness of a positive Kernig’s and, in babies, that the fontanelles are normal.

Poor communication and lack of continuityIn analysing what went wrong with cases that come to medico-legal attention, it is not uncommon to find problems of communication between doctors and parents or indeed between the various doctors who have been involved. General Practitioners should ensure that their practice arrangements allow for good transfer of information between doctors covering for each other, particularly if deputising services are used. 

Several doctors in succession seeing the same child over several days will upset the parents’ confidence and make it very difficult to detect subtle but significant changes in a child’s condition. The family may be disappointed and perhaps resentful at a ‘one-off’ consultation by someone they do not know and may never see again. This resentment will be remembered if things go wrong. In hospitals too, communication can break down unless proper ‘hand-over rounds’ are held and meticulous attention is paid to keeping progress notes up to date. The recent increase in the number of junior doctors providing ‘cross-cover’ to unfamiliar wards and the introduction of shift systems make it increasingly important to maintain this aspect of good practice.

Treating Suspected Meningitis The main point of this article is to encourage the earlier diagnosis of meningitis but mention should also be made of early treatment. It used to be thought ‘good practice’ to delay giving antibiotics until after obtaining blood cultures and ding a lumbar puncture to identify the responsible organism. However, as prior antibiotics do not appear to affect the yield of meningococci from throat swabs and there are other ways of confirming the diagnosis – such as antigen detection and polymerase chain reaction (PCR) testing on blood and CSF – there should be NO DELAY in instituting antibiotics as soon as the diagnosis is suspected. 

For meningococcal disease, guidelines to this effect have been issued and regularly updated since 1988. THE EXISTENCE OF THESE GUIDELINES MEANS THAT IT IS DBECOMING INCREASINGLY DIFFICULT TO DEFEND DOCTORS WHO DO NOT INSITITUE ANTIBIOTICS PROMPLY IN THESE CIRCUMSTANCES. General Practitioners should start antibiotics BEFORE transfer to hospital and that hospital doctors should start antibiotics before lumbar puncture. In practice this means starting antibiotics at the same time as blood is drawn for culture. In some circumstances however, such as when the child has developed focal neurological signs or decerebrate or decorticate posturing by the time of arrival at hospital, a lumbar puncture is contra-indicated. 

Conclusion ‘Missing’ meningitis is devastating to ALL involved. Following such an experience, doctors themselves have been known to be so distressed that they have found it necessary to leave general practice or to retire altogether. It is hoped that awareness of the problems detailed above will help to avoid at least some of these tragedies."

© Meningitis Foundation of America Inc. 1997, all rights reserved

 Meningitis Vaccination. Recommended for sub-Saharan Africa, Nepal, Dehli, Mecca.  Epidemics of meningococcal meningitis occur frequently during the dry season (December through June) across sub-Saharan Africa. This has always been a concern when traveling across the savannah areas which extend from Mali eastward to Ethiopia. In addition, large outbreaks of disease (over 100,000 cases) have been recently reported in Tanzania extending into parts of southern Kenya. Cases have also occurred in trekkers in Nepal and visitors to the old market areas of Dehli, India. Vaccination is required by Saudi Arabia for those embarking on the annual Haj pilgrimage to Mecca. 

Meningococcal meningitis is an infection of the covering of the brain and spinal cord. Common symptoms include fever and a stiff neck but the infection can lead to seizures, coma, or shock and can be fatal if treatment is delayed. 

Meningococcal meningitis is spread person to person, mainly by coughing and sneezing. The risk of contracting the disease increases if you will be spending time in close contact with the local population such as visiting crowded market areas. 

The disease is caused by the meningococcal bacteria, most commonly by serogroup A, but can also be caused by type C, or rarely type B. The vaccine that is available will protect against four strains of bacteria including type A,C,Y, and W, but will not protect against type B. A single dose of vaccine should offer protection for at least three years. The vaccine is both safe and effective and has been associated with minimal side-effects.  Gary P. Barnas, MD. Med Dir. MCW Intl Travelers Clinic


\11 Meningitis, Viral (Aseptic)

Meningitis is an illness in which there is inflammation of the tissues that cover the brain and spinal cord. Viral or aseptic meningitis, which is the most common type, is caused by an infection with one of several types of viruses. Meningitis can also be caused by infections with several types of bacteria or fungi. 

What are the symptoms of meningitis? The symptoms of meningitis may not be the same for every person. The more common symptoms are fever, severe headache, stiff neck, bright lights hurt the eyes, drowsiness or confusion, and nausea and vomiting. In babies, the symptoms are more difficult to identify. They may include fever, fretful- ness or irritability, difficulty in awakening the baby, or the baby refuses to eat.

Is viral meningitis a serious disease? Viral (aseptic) meningitis is serious but rarely fatal in persons with normal immune systems. Usually, the symptoms last from 7 to 10 days and the person recovers completely. Bacterial meningitis, on the other hand, can be very serious and result in disability or death if not treated promptly. Often, the symptoms of viral meningitis and bacterial meningitis are the same. For this reason, if you think you or your child has meningitis, see your doctor as soon as possible.

What causes viral meningitis? Many different viruses can cause meningitis. About 90% of cases of viral meningitis are caused by members of a group of viruses known as enteroviruses, such as coxsackieviruses and echoviruses. Herpesviruses and the mumps virus can also cause viral meningitis.

How is viral meningitis diagnosed? Viral meningitis is usually diagnosed by laboratory tests of spinal fluid obtained with a spinal tap. It can also be diagnosed by tests that identify the virus in specimens collected from the patient, but these tests are not usually done.

How is viral meningitis treated? No specific treatment for viral meningitis exists at this time. Most patients recover completely on their own, and doctors often will recommend bed rest, plenty of fluids, and medicine to relieve fever and headache.

Can I get viral meningitis if I'm around someone who has it? The viruses that cause viral meningitis are conta- gious. Enteroviruses, for example, are very common during the summer and early fall, and many people are exposed to them. However, most infected persons either have no symptoms or develop only a cold or rash with low-grade fever. Typically, fewer than 1 of every 1000 persons infected actually develop meningitis. Therefore, if you are around someone who has viral meningitis, you have a moderate chance of becoming infected, but a very small chance of developing meningitis.

How is the virus spread? Enteroviruses, the most common cause of viral meningitis, are most often spread through direct contact with respiratory secretions (e.g., saliva, sputum, or nasal mucus) of an infected person. This usually happens by shaking hands with an infected person or touching something they have handled, and then rubbing your own nose, mouth or eyes.

The virus can also be found in the stool of persons who are infected. The virus is spread through this route mainly among small kids who are not yet toilet trained. It can also be spread this way to adults changing the diapers of an infected infant.

The incubation period for enteroviruses is usually between 3-7 days from the time you are infected until you develop symptoms. You can usually spread the virus to someone else beginning about 3 days after you are infected until about 10 days after you develop symptoms.

How can I reduce my chances of becoming infected? Because most persons who are infected with enteroviruses do not become sick, it can be difficult to prevent the spread of the virus. If you are in contact with someone who has viral meningitis, however, the most effective method of prevention is to wash your hands thoroughly and often. 

In institutional settings such as child care centers, washing objects and surfaces with a dilute bleach solution (made by mixing 1 capful of chlorine-containing household bleach with 1 gallon water) can be a very effective way to inactivate the virus. 

For further info, contact the Respiratory and Enteric Viruses Branch, National Center for Infectious Diseases, at 404-639-3607 (tel) or 404-639-4960 (fax).    


\12 Newcastle disease

Newcastle disease also called AVIAN PNEUMOENCEPHALITIS, a serious viral disease of birds caused by a paramyxovirus and marked by respiratory and nervous system problems. Some adult birds recover, although mortality rates are high in tropical and subtropical regions. Young chickens are especially susceptible and rarely survive. Symptoms are variable in turkeys and almost absent in ducks. There is no effective treatment. Vaccines are available and are given repeatedly for best protection. Humans can become infected by handling sick birds but usually develop only a temporary conjunctivitis (inflammation of the mucous membrane lining the inner surface of the eyelid). 
An outbreak of exotic Newcastle can have severe economic impacts. In 1971, a major outbreak occurred in commercial poultry flocks in southern California. The disease threatened not only the California poultry industry but the entire U.S. poultry and egg supply. In all, 1,341 infected flocks were identified, and almost 12 million birds were destroyed. Eradication efforts cost taxpayers $56 million, severely disrupted the operations of many producers, and increased the prices of poultry and poultry products to consumers. Exotic Newcastle has not infected domestic chicken flocks in the United States since that outbreak was eradicated in 1974. 

What Are the Clinical Signs? Exotic Newcastle affects the respiratory, nervous, and digestive systems. The incubation period for the disease ranges from 2 to 15 days. An infected bird may exhibit the following signs:

Respiratory: sneezing, gasping for air, nasal discharge, coughing  Digestive: greenish, watery diarrhea  Nervous: depression, muscular tremors, drooping wings, twisting of head and neck, circling, complete paralysis,  Partial to complete drop in egg production and thin-shelled eggs,  Swelling of the tissues around the eyes and in the neck,  Sudden death, Increased death loss in a flock. 

How Does Exotic Newcastle Spread? Exotic Newcastle is spread primarily through direct contact between healthy birds and the bodily discharges of infected birds. The disease is transmitted through infected birds' droppings and secretions from the nose, mouth, and eyes. Exotic Newcastle spreads rapidly among birds kept in confinement, such as commercially raised chickens.

High concentrations of the exotic Newcastle virus are in birds' bodily discharges; therefore, the disease can be spread easily by mechanical means. Virus-bearing material can be picked up on shoes and clothing and carried from an infected flock to a healthy one. The disease is often spread by vaccination and debeaking crews, manure haulers, rendering-truck drivers, feed delivery personnel, poultry buyers, egg service people, and poultry farm owners and employees.

The exotic Newcastle virus can survive for several weeks in a warm and humid environment on birds' feathers, manure, and other materials. It can survive indefinitely in frozen material. However, the virus is destroyed rapidly by dehydration and by the ultraviolet rays in sunlight.

Smuggled pet birds, especially Amazon parrots from Latin America, pose a great risk of introducing exotic Newcastle into U.S. poultry flocks. Amazon parrots that are carriers of the disease but do not show symptoms are capable of shedding exotic Newcastle virus for more than 400 days. 

How Can Poultry Producers Help Control and Prevent Exotic Newcastle? The only way to eradicate exotic Newcastle from commercial poultry is by rapidly destroying all infected flocks and imposing strict quarantine and indepth surveillance programs. Poultry producers should strengthen biosecurity practices to prevent the introduction of the disease to their flocks. Biosecurity is also important to protect backyard and hobby flocks. The following are tips on proper biosecurity practices:

Permit only essential workers and vehicles on the premises.  Provide clean clothing and disinfection facilities for employees.  Clean and disinfect vehicles (including tires) entering and leaving the premises.  Avoid visiting other poultry operations.  Maintain an "all-in-all-out" philosophy of flock management with a single age flock.  Control the movement of all poultry and poultry products from farm to farm.  Do not "skim" mature birds from a flock for sale to a live-poultry market.  Clean and disinfect poultry houses between each lot of birds.  Do not keep pet birds on the farm. Do not hire employees who own pet birds.  Exclude vaccination crews, catching crews, and other service personnel who may have been in contact with other poultry operations within 24 hours.  Protect flocks from wild birds that may try to nest in poultry houses or feed with domesticated birds.  Control movements associated with the disposal and handling of bird carcasses, litter, and manure.  Take diseased birds to a diagnostic laboratory for examination. Keep dead birds in a refrigerator and ship them on wet ice to a diagnostic laboratory for virus isolation. 
 

How Can Pet Bird Enthusiasts Help Control and Prevent Exotic Newcastle?

Exotic Newcastle is also a threat to the caged-bird industry. Birds illegally smuggled into the United States are not quarantined and tested by the U.S. Department of Agriculture (USDA) and therefore may carry the exotic Newcastle virus. Owners of pet birds should

Request certification from suppliers that birds are legally imported or are of U.S. stock, are healthy prior to shipment, and will be transported in new or thoroughly disinfected containers.  Maintain records of all sales and shipments of flocks.  Isolate all newly purchased birds for at least 30 days. Restrict movement of personnel between new and old birds.

Amazon parrots are difficlut to raise domestically. Anyone who is offering to sell a large number of young parrots should be suspected of smuggling or purchasing smuggled birds. 

What Is APHIS' Role? To prevent exotic Newcastle from being introduced into U.S. poultry flocks, USDA's Animal and Plant Health Inspection Service (APHIS) requires that all imported birds (poultry, pet birds, birds exhibited at zoos, and ratites) be tested and quarantined for diseases before entering the country.

In addition to international import restrictions, APHIS has increased surveillance efforts to detect exotic Newcastle if it is accidentally introduced into the United States. More than 250 APHIS and State veterinarians trained to diagnose foreign animal diseases regularly conduct field investigations of suspicious disease conditions. This surveillance is enhanced by efforts from university personnel, State animal health officials, USDA-accredited veterinarians, and industry representatives.

If exotic Newcastle were detected in domestic poultry or pet birds, APHIS would work quickly with its State and industry counterparts to implement aggressive measures, including quarantine, control, and cleanup, to prevent opportunities for the disease to spread.

The following are approved disinfectants for vehicles, premises, rubber boots, gloves, raincoats, and goggles:

One-stroke Environ: one-half ounce to 1 gallon of water.  Sodium orthophenyl-phenate: 1 pound to 12 gallons of water at 15.6 °C (60 °F) in warm weather. In cold weather, the solution must be heated to at least 49 °C (120 °F) before application.  Cresylic disinfectant: 4 ounces to 1 gallon of water.  Thermal heat: This is used to destroy viruses in poultry products. The temperature must remain constant for the duration of time indicated.  At least 69 °C (156 °F) for 30 minutes or more.  At least 80.5 °C (167 °F) for 3 minutes.  Report Suspicious Cases

Any poultry or pet bird owners or veterinarians who suspect a bird may have exotic Newcastle should immediately contact State or Federal animal health authorities.

USDA, APHIS, Veterinary Services, Emergency Programs 4700 River Road, Unit 41, Riverdale, MD 20737-1231 Telephone (301) 734-8073, Fax (301) 734-7817
 
                   
    -- LAVERLAM S.A. NEWCASTLE (Poultry Disease) is caused by a virus belonging to the Mixoviridae family of which there is only one serotype. However, there are different pathogens that cause different clinical signs.

The velogenic neurothropic and viscerothropic, produce a disease with high mortality rates and the appearance of nervous and visceral signs. The less virulent mesogenic forms, could cause serious respiratory symptoms and an afterwards paralysis, specially on young or poorly immunized birds.

The mild strains, are those used for the production of live virus vaccines: LaSota strain, Clone LaSota strain, and B1 Hitchner strain. There are no side effects besides a slight respiratory reaction 4 to 5 days after the vaccine has been applied. This reaction is temporary and totally harmless. Any other manifestation is abnormal and would indicate the prescence of secondary infections such as Mycoplasma galliseticum and the M. sinoviae.

The disease is diagnosed through its clinical signs, the virus isolation and serologic tests like HI and Elisa.

The vaccines recommended for this disease are NEWCASTLE B1 or NEWCASTLE CLONE LASOTA Strain or NEWCASTLE LASOTA Strain or LAYVAC all made by LAVERLAM S.A. 

                   
    --Newcastle Disease (ND) is a Paramyxovirus Type 1 disease or chickens, turkeys, wild and pet birds. Clinically, ND varies widely depending on the virus strain and host species. Generally chickens are highly susceptible with turkeys and pidgeons less so. Ducks and geese are resistant, with peafowl, guineafowl, pheasant, and quail exhibiting mild disease. Generally, there is no persistent infection in domestic poultry. In Psittacine birds, a chronic infection may develop in the kidneys with potential for long-term shedding. ND is present in most countries but pathogenic strains are exotic to Canada and the U.S.A. ND has been reported in wild birds in Canada in 1995. 

The virus (NDV) is relatively stable in nature, remaining infective for weeks at low temperature and surviving for several hours in a wide range of ph (3-10). In litter it can survive for 20 days, and in water, soil, carcasses, eggs and feathers for 255 days. It survives in meat and bone for 6 months at 1 º C., but can be eliminate by paasteurization of eggs and egg products at 64 º C for 4.5 minutes, rendering for several minutes at 100 º C, processing meat for 30 minutes at 30 º C or 1 minute at 80 º C. Transmission is by contact with infected products or by aerosol from infected live birds.  Mechanical transmission between premises can occur on footwear, clothing, skin, feed, trucks, and poultry or egg handling equipment. 

The incubation period is 2-6 (up to 15) days. In chickens, outbreaks may be so severe that almost all of the affected flock may dies within 72 hours without showing clinical signs. Pidgeons can show mortality of up to 80%, while ducks and geese are usually less than 10%, although large die-oofs have been report in the wild. Canaries generally show a mild disease with low mortality. 

Humans can be infected with NDV, with headache, flu-like symptoms and mild conjunctivitis (4-7 days) rarely becoming severe or leading to visual impairment. Most infections are in laboratory personnel. 

Pathogenic strains of ND cause sudden onset of depresssion, rapid breathing and anorexia in all ages of birds, and a sharp drop in egg production in laying hens. The viscerotropic pathogenic strain may cause edema of the head and bright green or bloody diarrhea as prominent clinical features. Neurogenic pathogenic strains are characterized by marked nervous signs such as torticollis (twisting of the neck), tremors or paralysis. Mobidity and mortality with all pathogenic strains may rapidly exceed 90% in chickens and turkeys. Infected pet birds may show mild to severe respiratory, enteric and/or neurologic signs and shed virus for several months. 

Pathogenic strains are exotic in commercial poultry operations in Canada. The major risk is from migratory wild birds carrying the disease into the country, or from undeclared infected pets birds (especially psittacine) brought into Canada from other countries


\13 Stress

In psychology and biology, any strain or interference that disturbs the functioning of an organism. The human being responds to physical and psychological stress with a combination of psychic and physiological defenses. If the stress is too powerful, or the defenses inadequate, a psychosomatic or other mental disorder may result.
 Stress is an unavoidable effect of living and is a complex phenomenon in modern technological society. There is little doubt that one's success or failure in control- ling potentially stressful situations can have a profound effect on his ability to function. The ability to "cope" with stress has figured prominently in psychosomatic research. Researchers have reported a statistical link between coronary heart dis- ease and individuals exhibit- ing stressful behavioral patterns designated "Type A." These patterns are reflected in a style of life charact- erized by impatience and a sense of time urgency, hard- driving competitiveness, and preoccupation with voca- tional and related deadlines.
 Various strategies have been successful in treating psychological and physiological stress. Moderate stress may be relieved by exercise and any type of meditation (eg, yoga or Oriental meditative forms). Severe stress may require psychotherapy to uncover and work through the underlying causes. A form of behaviour therapy known as biofeedback enables the patient to become more aware of internal processes and thereby gain some control over bodily reactions to stress. Sometimes, change of environ- ment or living situation may produce therapeutic results.

 The Medical Basis of Stress, Depression, Anxiety, Sleep Problems, and Drug Use (presented FREE for you to read) Explained in Fun, Easy to Read, Format

Recognizing Stress - Which of these is stress? You receive a promotion at work. Your car has a flat tire. You go to a fun party that lasts till 2:00 a.m. Your dog gets sick. Your new bedroom set is being delivered. Your best friend and his wife come to stay at your house for a week. You get a bad case of hay fever. All of the above. 

ALL OF THESE ARE STRESS If you are used to thinking that stress is something that makes you worry, you have the wrong idea of stress. Stress is many different kinds of things: happy things, sad things, allergic things, physical things. Many people carry enormous stress loads and they do not even realize it!

WHAT IS STRESS? We are all familiar with the word "stress". Stress is when you are worried about getting laid off your job, or worried about having enough money to pay your bills, or worried about your mother when the doctor says she may need an operation. In fact, to most of us, stress is synonymous with worry. If it is something that makes you worry, then it is stress.

Your body, however, has a much broader definition of stress. TO YOUR BODY, STRESS IS SYNONYMOUS WITH CHANGE. Anything that causes a change in your life causes stress. It doesn't matter if it is a "good" change, or a "bad" change, they are both stress. When you find your dream apartment and get ready to move, that is stress. If you break your leg, that is stress. Good or bad, if it is a CHANGE in your life, it is stress as far as your body is concerned.

Even IMAGINED CHANGE is stress. (Imagining changes is what we call "worrying".) If you fear that you will not have enough money to pay your rent, that is stress. If you worry that you may get fired, that is stress. If you think that you may receive a promotion at work, that is also stress (even though this would be a good change). Whether the event is good or bad, imagining changes in your life is stressful.

Anything that causes CHANGE IN YOUR DAILY ROUTINE is stressful. Anything that causes CHANGE IN YOUR BODY HEALTH is stressful. IMAGINED CHANGES are just as stressful as real changes. Let us look at several types of stress -- ones that are so commonplace that you might not even realize that they are stressful.......

Emotional Stress When arguments, disagreements, and conflicts cause CHANGES in your personal life -- that is stress.

Illness Catching a cold, breaking an arm, a skin infection, a sore back, are all CHANGES in your body condition.

Pushing Your Body Too Hard A major source of stress is overdriving yourself. If you are working (or partying) 16 hours a day, you will have reducedyour available time for rest. Sooner or later, the energy drain on your system will cause the body to fall behind in its repair work. There will not be enough time or energy for the body to fix broken cells, or replace used up brain neurotransmitters. CHANGES will occur in your body's internal environment. You will "hit thewall," "run out of gas". If you continue, permanent damage may be done. The body's fight to stay healthy in the face of the increased energy that your are expending is major stress.

Environmental Factors Very hot or very cold climates can be stressful. Very high altitude may be a stress. Toxins or poisons are a stress. Each of these factors threatens to cause CHANGES in your body's internal environment.

The Special Case of Tobacco Use Tobacco is a powerful toxin!! Smoking destroys cells that clean your trachea, bronchi, and lungs. Smoking causes emphysema and chronic bronchitis, which progress to slow suffocation. The carbon monoxide from cigarette smoking causes chronic carbon monoxide poisoning. Tobacco use damages the arteries in your body, causing insufficient blood supply to the brain, heart, and vital organs. Cigarette smoking increases the risk of cancer 50 fold. Chewing tobacco or snuff is no safe haven. It also damages your arteries, and it carries the same cancer risk. (Cancers of the head and neck are particularly vicious, disfiguring, and deadly). Poisoning the body with carbon monoxide, and causing the physical illnesses of emphysema, chronic bronchitis, cancer, and arterial damage, tobacco is a powerful source of added stress to one's life.

Hormonal Factors PUBERTY The vast hormonal changes of puberty are severe stressors. A person's body actually CHANGES shape, sexual organs begin to function, new hormones are released in large quantities. Puberty, as we all know, is very stressful. PRE-MENSTRUAL SYNDROME Once a woman passes puberty, her body is designed to function best in the presence of female hormones. For women past puberty, a lack of female hormones is a major stress on the body. Once a month, just prior to menstruation, a woman's hormone levels drop sharply. In many women, the stress of sharply falling hormones is enough to create a temporary OVERSTRESS. This temporary OVERSTRESS is popularly known as Pre MenstrualSyndrome (PMS). POST-PARTUM Following a pregnancy, hormone levels CHANGE dramatically. After a normal childbirth, or a miscarriage, some women may be thrown into OVERSTRESS by loss of the hormones of pregnancy. MENOPAUSE There is another time in a woman's life when hormone levels decline. This is the menopause. The decline in hormones during menopause is slow and steady. Nevertheless, this menopausal decline causes enough stress on the body to produce OVERSTRESS in many women.

Taking Responsibility for Another Person's Actions When you take responsibility for another person's actions, CHANGES occur in your life over which you have little or no control. Taking responsibility for another person's actions is a major stressor.

Allergic Stress Allergic reactions are a part of your body's natural defense mechanism. When confronted with a substance which your body considers toxic, your body will try to get rid of it, attack it, or somehow neutralize it. If it is something that lands in your nose, you might get a runny, sneezy nose. If it lands on your skin, you might get blistery skin. If you inhale it, you'll get wheezy lungs. If you eat it, you may break out in itchy red hives all over your body. Allergy is a definite stress, requiring large changes in energy expenditure on the part of your body's defense system to fight off what the body perceives as a dangerous attack by an outside toxin.

Your Stress Scale In the following table you can look up representative changes in your life and see how much stress value each of these changes is adding to your life. NOTE ANY ITEM THAT YOU MAY HAVE EXPERIENCED IN THE LAST TWELVE MONTHS. Then, total up your score. (Adapted from the "Social Readjustment Rating Scale" by Thomas Holmes and Richard Rahe. This scale was first published in the "Journal of Psychosomatic Research", Copyright 1967, vol.II p. 214. It is used by permission of Pergamon Press Ltd.)
 STRESS EVENT VALUES
 1. DEATH OF SPOUSE 
 100 2. DIVORCE 
 60 3. MENOPAUSE 
 60 4. SEPARATION FROM LIVING PARTNER 
 60 5. JAIL TERM OR PROBATION 
 60 6. DEATH OF CLOSE FAMILY MEMBER OTHER THAN SPOUSE 
 60 7. SERIOUS PERSONAL INJURY OR ILLNESS 
 45 8. MARRIAGE OR ESTABLISHING LIFE PARTNERSHIP 
 45 9 .FIRED AT WORK 
 45 10.MARITAL OR RELATIONSHIP RECONCILIATION 
 40 11.RETIREMENT 
 40 12.CHANGE IN HEALTH OF IMMEDIATE FAMILY MEMBER 
 40 13.WORK MORE THAN 40 HOURS PER WEEK 
 35 14.PREGNANCY OR CAUSING PREGNANCY 
 35 15.SEX DIFFICULTIES 
 35 16.GAIN OF NEW FAMILY MEMBER 
 35 17.BUSINESS OR WORK ROLE CHANGE 
 35 18.CHANGE IN FINANCIAL STATE 
 35 19.DEATH OF A CLOSE FRIEND (not a family member) 
 30 20.CHANGE IN NUMBER OF ARGUMENTS WITH SPOUSE OR LIFE PARTNER 30 21.MORTGAGE OR LOAN FOR A MAJOR PURPOSE 
 25 22.FORECLOSURE OF MORTGAGE OR LOAN 
 25 23.SLEEP LESS THAN 8 HOURS PER NIGHT 
 25 24.CHANGE IN RESPONSIBILITIES AT WORK 
 25 25.TROUBLE WITH IN-LAWS,OR WITH CHILDREN 
 25 26.OUTSTANDING PERSONAL ACHIEVEMENT 
 25 27.SPOUSE BEGINS OR STOPS WORK 
 20 28.BEGIN OR END SCHOOL 
 20 29.CHANGE IN LIVING CONDITIONS (visitors in the home,
 change in roommates, remodeling house) 
 20 30.CHANGE IN PERSONAL HABITS (diet, exercise,
 smoking, etc.) 
 20 31.CHRONIC ALLERGIES 
 20 32.TROUBLE WITH BOSS 
 20 33.CHANGE IN WORK HOURS OR CONDITIONS 
 15 34.MOVING TO NEW RESIDENCE 
 15 35.PRESENTLY IN PRE-MENSTRUAL PERIOD 
 15 36.CHANGE IN SCHOOLS 
 15 37.CHANGE IN RELIGIOUS ACTIVITIES 
 15 38.CHANGE IN SOCIAL ACTIVITIES (more or less than before)
 15 39.MINOR FINANCIAL LOAN 
 10 40.CHANGE IN FREQUENCY OF FAMILY GET-TOGETHERS 
 10 41.VACATION 
 10 42.PRESENTLY IN WINTER HOLIDAY SEASON 
 10 43.MINOR VIOLATION OF THE LAW 
 5
 TOTAL SCORE:_________________
 We have asked you to look at the last twelve months of changes in your life. This may surprise you. It is crucial to understand, however, that a major change in your life has effects that carry over for long periods of time. It is like dropping a rock into a pond. After the initial splash, you will experience ripples of stress. And these ripples may continue in your life for at least a year. So, if you have experienced total stress within the last twelve months of 250 or greater, even with normal stress tolerance, you may be OVERSTRESSED. Persons with Low Stress Tolerance may be OVERSTRESSED at levels as low as 150.

OVERSTRESS will make you sick. Carrying too heavy a stress load is like running your car engine past the red line; or leaving your toaster stuck in the "on" position; or running a nuclear reactor past maximum permissible power. Sooner or later, something will break, burnup, or melt down. What breaks depends on where the weak links are in your physical body. And this is largely an inherited characteristic.

Here are the common "weak links", and the symptoms of their malfunction Brain OVERSTRESS Fatigue, aches and pains, crying spells, depression, anxiety attacks, sleep disturbance. Gastrointestinal Tract Ulcer, cramps and diarrhea, colitis, irritable bowel. Glandular System Thyroid gland malfunction. Cardiovascular High blood pressure, heart attack, abnormal heart beat, stroke. Skin Itchy skin rashes. Immune System Decreased resistance to infections and neoplasm. We have known for a long time that OVERSTRESS could cause physical damage to the gastrointestinal tract, glandular system, skin or cardiovascular system. But only recently have we learned that OVERSTRESS actually causes physical changes in the brain. One of the most exciting medical advances of our decade has been an understanding of how OVERSTRESS physically affects your brain. We now know that the fatigue, aches and pains, crying spells, depression, anxiety attacks and sleep disturbances of OVERSTRESS are caused by brain CHEMICAL MALFUNCTION. Here is how it works...

How to Deal with OVERSTRESS Depression, anxiety attacks, hypochondriasis, alcoholism, compulsive gambling, insomnia, stress-o-holism, these are all names given to SYMPTOMS of OVERSTRESS; or to the major Pick-Me-Up that the person is using for self-medication. In the past, each of these has been thought to be a disease in and-of-itself. We now know that each of these is not a disease in-and-of itself but may be a result of Happy Messenger malfunction, and the person's largely futile efforts to self-medicate with Pick-Me-Up's or Put Me-Down's. The great breakthrough of the 1990's is our understanding of how all this works. We now have tools that can help a person suffering from OVERSTRESS to feel healthy again, sleep well, and be rid ofaches, pains, anxiety, and depression.

The Treatment of OVERSTRESS The BIGGEST MISTAKE you can make in handling stress is... Using Pick-Me-Up's to boost your Happy Messengers, while continuing to pile on the stress. When you do this, you "Ride the Wild Rollercoaster": Sometimes feeling well, mostly feeling ill, never achieving balance.

What you should do is... Stop using the Pick-Me-Up's, lower your stress level, and give your body a chance to re-balance itself. Then you can achieve balance, feel well, and STAY well. OVERSTRESS IS TREATED BY REDUCING YOUR STRESS LOAD

Add up your Stress Scale points for the past twelve months. If it is above 250, you should be keenly alert for the early signs of OVERSTRESS. Even a level of 150 will OVERSTRESS ten percent of persons. For this reason, it is best to aim for a continuing stress load of below 150 on the Stress Scale.

Here are TEN SIMPLE WAYS TO to REDUCE YOUR STRESS LOAD... 1. MAKE YOUR LIFE REGULAR... as "clock work" If you suffer from OVERSTRESS, you have disrupted the function of your Body Clock. Re-setting your Body Clock is vital if you are to feel well, sleep soundly, and awake refreshed. Give yourself a definite wake up and sleep time. This sets a frame of reference for your Body Clock. It will take two or three weeks to synchronize your Body Clock to your schedule. So, stick to your schedule!

But what if I try to go to sleep at 10 p.m. and I can't fall asleep? Or what if I fall asleep but keep waking up during the night? Sleep difficulty is the hallmark of OVERSTRESS. When your Body Clock stops working, you may have trouble falling asleep and staying asleep. Or conversely, you may feel sleepy all the time. Either symptom may be produced when the Body Clock stops working. It all depends on which "position" the Clock was in when it stops: wakefulness, or sleepiness.

So, do not expect to have your sleep problems go away until your Body Clock is working again. Go ahead and set yourself a reasonable wake up time and bed time. Do the best you can to stick to these times. As you lower your stress levels, your Body Clock will begin to work. It will then match its cycle ofwakefulness and sleep to the times that you have set for it. Remember, this process will take at least three weeks, so stick firmly to your time schedule. But what if I put myself to bed at my bed time, and I just lie there without falling asleep?

If, after 45 minutes, you have not fallen asleep, get up and read a book or do something around the house. Sooner or later, you will feel sleepy and fall asleep. Keep putting yourself to bed at your bed time every night. As you reduce your stress levels, your Body Clock will begin working. Your Body Clock will gradually match your chosen sleep schedule. In the meantime, be patient and work to reduce your stress levels as much as possible.

If You Must do "Shift Work": Your Body Clock will always try and synchronize itself with your daily schedule. If your job requires you to work varying shifts, however, you may have difficulty in getting your Body Clock to match your shift. When properly synchronized, your Body Clock tells you to be awake for your work, and tells you to go to sleep after your work. If you do evening work, your Body Clock will shift itself so that you will be awake for your evening work, and be able to sleep during the day. But this change requires two or three weeks to occur. If your employer rotates your shift more often than every two or three weeks, your Body Clock will always be mis-matched with your work requirements. You will be trying to work when your body wants to sleep, and trying to sleep when your body wants to work. This will make it practically impossible to restore the proper functioning of your Body Clock.

If you are OVERSTRESSED, you should avoid "shift work". If you MUST do "shift work", try and work at least three weeks at each shift before rotating to a new one. And always make sure the direction of shift rotation to is "morning to evening to night to morning again". Do you remember that the untrained cycle of your body clock is 25 hours? Because of this, it is always easier to stay up later, than to try and force yourself to go to bed early. So never try to rotate shifts from "night to evening to morning". Your Body Clock will blow a fuse.

If Your Work Involves Air Travel to Different Time Zones: Those of you who do frequent long distance air traveling will be familiar with the condition known as "Jet Lag". Jet Lag occurs when you board an airplane and rapidly move to an area where the local time is more than three to four hours different than the time on your Body Clock. You might, for instance, board a jet in Hawaii and fly to New York. When you arrive in NewYork, it might be midnight New York Time, but only 6 p.m. on your Body Clock.

All you body rhythms: temperature, stress fighting hormone, sleep cycles are now out of synchronization with your local time zone. Now you are trying to go to sleep when your body is still awake, and trying to work when your body expects you to be in bed. It will take two or three weeks for your Body Clock to harmonize with your new surroundings. During that time it is not unusual to be fatigued and to feel "not with it". We call this feeling "Jet Lag".

If you are OVERSTRESSED, you should avoid inter-time zone traveling. But if you MUST change time zones, try to wait at least three weeks between trips. And when you do take that trip, and you arrive in a new time zone, it will be easier for you to adjust if you stay up later, rather than trying to force yourself to sleep when your body wants to be awake.

If You Work Indoors: Your body Clock requires exposure to daylight during the day in order to remain synchronized with your local time zone. Normal fluorescent lighting does not have the same light spectrum as daylight, hence it will NOT help your Body Clock to properly set itself. If you are a person who arises when it is dark, works indoors all day, and goes home when it is dark, your BodyClock may become out of phase with the world around you - giving you a case of permanent "Jet Lag". Because of this problem, manufacturers of fluorescent lights have begun producing "daylight spectrum" fluorescent lights. These lights will allow your Body Clock to synchronize itself with your work schedule.

If you work indoors, try to work by a window. If you cannot, then see if you can have "daylight spectrum" fluorescent light bulbs installed. It really helps. As an alternative for people who never seen the sun, one can sit facing 600 watts of daylight spectrum fluorescent lights, three feet in front of you, for one hour. Do this at the time that you wish your Body Clock to learn to wake you up. You may eat breakfast, read a book, or watch television, but the light must be facing you. (Caution is required with light therapy in people with manic depressive disorders, skin that is sensitive to light, or medical conditions that make the eyes vulnerable to light damage - consult physician first.) Note that persons living in northern climates lacking in sunshine may have the same problem of permanent "Jet Lag". It is so common it has been named "Seasonal Affective Disorder" or "SAD" for short. For these people the above suggestion will be equally helpful.

2. GIVE YOURSELF A BREAK TODAY You must give your body adequate time to repair itself, and to regenerate Happy Messengers. If you are having symptoms of OVERSTRESS: Fatigue Aches and pains Anxiety Problems sleeping Lack of enjoyment of life Depression Give your body a chance to heal itself. Every morning make a list of things that you want to ge done... THEN, CUT OFF THE BOTTOM HALF OF THIS LIST!

3. LIGHTEN UP YOUR LOAD OF SOCIAL ENGAGEMENTS Let someone else do the holiday dinner for the family, or make it a pot luck on paper plates. Only go out once this week. Tell your visitors from out of town (who always expect to stay at your house) to call you "just as soon as they get settled in a hotel room". SAY "NO" A LOT MORE OFTEN TO REQUESTS FROM OTHERS OF YOUR TIME.

4. POSTPONE MAKING ANY CHANGES IN YOUR LIVING ENVIRONMENT Remember, CHANGE IS STRESS. So relax, postpone any big moves or changes for awhile. Postpone remodeling your home or apartment. Postpone moving to a new house or apartment. Making a change in your living environment, even if it is a change that you are excited about, is a major stress. It will add a minimum of 25 stress points to your life; and, if it is a financial strain, may add as much as 65 stress points! When you consider that you would like to reduce your stress level to 150 or below, you will see why postponing a change in your living environment will be very helpful in obtaining that goal.

5. REDUCE THE NUMBER OF HOURS YOU SPEND AT WORK OR SCHOOL If you are a "workaholic", or a "school-a-holic", you need to reduce the energy drain you are placing on your body. Work or school more than 40 hours per week adds 40 stress points to your life. TAKE SOME TIME OFF

6. THE OVERSTRESS DIET Keep Your Blood Sugar Steady People who are OVERSTRESSED almost always begin to use sugar as a Pick-Me-Up. Their blood sugar goes up and down wildly. Thus, the most important dietary consideration is to keep your blood sugar from swinging high, or swinging low. In order to feel well, you must level out your blood sugar, avoiding the"sugar highs", and "sugar lows". Take your sugar in the form of complex carbohydrates, such as cereals, rice, pasta, bread and potatoes. These foods, comprised of tightly interlinked sugars, are broken down slowly by the body, releasing their sugar over a long period of time. Eating frequent small meals, instead of a few large ones, also helps keep your blood sugar stable.

Eat More Vegetables Your brain's production of one of the Happy Messengers, Serotonin, is sensitive to your diet. Eating more vegetables, can increase your brain's Serotonin production. This increase is due to improved absorption of the amino acid L-Tryptophan. (Vegetables contain the natural, safe, form of L Tryptophan. At the present writing, synthetic L-Tryptophan has been removed from health food stores due to probable impurities that were, in some cases, causing severe and even fatal illness). Meats contain natural L-Tryptophan also, but when you eat meat, the L-Tryptophan has to compete with so many other amino acids for absorption that the L-Tryptophan loses out. The net result is that you get better absorption of L-Tryptophan when you eat vegetables. In other words -- eat a salad for lunch.

You should also take a good multi-vitamin and mineral preparation. Here is a formula which is representative of such a vitamin. Such a vitamin is available at most any drug store. It is best to take such a vitamin once each day. Vitamin A 5000 I.U. Vitamin E 30 I.U. Vitamin C up to: 250 mg Folic Acid 400 mcg Vitamin B1 (Thiamine) 2.25 mg Vitamin B2 (Riboflavin 2.6 mg Niacinamide 20 mg Vitamin B6 (Pyridoxine) 3 mg Vitamin B12 9 mcg Vitamin D 400 I.U. Biotin 45 mcg Pantothenic Acid 10 mg Calcium 162 mg Phosphorus 125 mg Iodine 150 mcg Iron 27 mg Magnesium 100 mg Copper 2 mg Manganese 5 mg Potassium 30 mg Chloride 27.2 mg Chromium 25 mcg Molybdenum 25 mcg Selenium 25 mcg Zinc 15 mg Vitamin K 125 mcg

7. REDUCE YOUR USE OF PICK-ME-UP'S Beware of Cue Reactions To cut down on your intake of Pick-Me-Up's, remove them from the house, and any other place that is within easy reach. Do not forget to clear your desk drawer at work, and the glove compartment of the car. Even though you want to reduce your sugar, caffeine, tobacco or alcohol consumption, just the sight of a cookie can lead you to eat it; just the sight of a beer might lead you to drink it -- before you even have a chance to stop yourself.

8. AVOID ALLERGIES Allergy is a major source of stress for some of us. If there are certain things that trigger YOUR allergies, you should avoid them.

9. START AN ENJOYABLE EXERCISE - REST YOUR MIND Begin an exercise that you enjoy, Preferably, do something that brings you into contact with other people. The value of such exercise, three times a week for 20 minutes to two hours, can not be over emphasized. Enjoyable exercise, in moderation, boosts your HAPPY MESSENGERS in a smooth sustained fashion. It will make you feel better right away! Exercise has another beneficial effect. Most people, when exercising, do not worry. They are actually resting the nerve cells in the brain that worry, giving those cells time to renew their stores of HAPPY MESSENGERS, so they can function normally the next time they are needed. There are other ways of "resting your mind". Dancing, listening to music, reading, working on a craft, playing a musical instrument, meditation, self relaxation, and biofeedback also relieve stress. Any activity which concentrates your attention on a subject other than life's problems will help rest your mind. This rests the "Problem Solving" part of your brain, allowing it to regenerate HAPPY MESSENGERS and renew itself.

10. STOP YOUR PUT-ME-DOWN'S Tranquilizers and calmatives will prevent your body from restoring its Happy Messengers. Unlike Pick-Me-Up's, which can usually be taken in modest amounts without harm, Put-Me-Down's should be avoided altogether. By reducing your stress load, stabilizing your blood sugar, improving your diet, avoiding allergies, and getting some exercise, you will find you will not want tranquilizers and calmatives. Before stopping any prescription medicine, however, always, check with your doctor. We do not want you to accidentally stop a heart medicine or anti-epilepsy medication. Also, many of the Put-Me-Down's must be tapered down slowly, rather than stopped abruptly. Ask your doctor before you make any change in medication. (If someone has given you Put-Me-Down's to help you sleep, particularly the ones in the Valium family, you may have a real problem stopping them. They are best tapered off very slowly, and under medical supervision. Even then, the withdrawal symptoms from these drugs are very unpleasant. The chief withdrawal symptoms is inability to sleep, and vivid disturbing dreams. If you try to stop them on your own, you may experience sleeplessness that is worse than ever! Then you may erroneously conclude that you need more, not less of the Put-Me-Down! It is very easy to be trapped by Put-Me-Down's.)

If the Ten Simple Steps are Not Enough If you have done all of the preceding and still have significant symptoms of OVERSTRESS:

Fatigue Aches and pains Anxiety Problems sleeping Lack of enjoyment of life Depression THEN IT IS TIME YOU OBTAINED SOME ASSISTANCE...

VISIT YOUR DOCTOR OVERSTRESS that you can not clear up yourself may be the earliest warning sign of some hidden illness. Thyroid disease Calcium imbalance (too much or too little) Anemia Diabetes Manic-depression (Bi-polar disorder) Liver disease Kidney malfunction Vitamin deficiency Hormone deficiency 

These are examples of physical illnesses that you might not be aware of - but which cause enough stress on your body to create OVERSTRESS. Your doctor should do a thorough history, and a complete physical examination, including tests on blood and urine. The automated blood testing machines can do a complete blood count, as well as measure your thyroid function, liver enzymes, kidney function, calcium and phosphorus, iron and blood sugar for a very reasonable price. So, if your symptoms are not getting better with the TEN SIMPLE STEPS -- be sure to see your doctor.

ELIMINATE YOUR PICK-ME-UP'S ENTIRELY If cutting down your Pick-Me-Up's did not get you off the"roller coaster" of Pick-Me-Up high and Pick-Me-Up low, then you need to ELIMINATE Pick-Me-Up's entirely. You need to get off the"roller coaster" in order to start feeling well. If you have a heavy intake of Pick-Me-Ups, do not despair. Today, physicians have many ways to help you stop your Pick-Me-Up's. A brain chemical rebalancer can support your Happy Messengers while you eliminate the Pick-Me-Ups from your system. Also, your doctor has other medications that can specifically block the craving for most Pick-Me-Up's. These medicines must be prescribed by a physician after evaluating whether they are safe for you. If you are a heavy user of alcohol, sugar, caffeine, cigarettes, cocaine, heroin or ANY of the Pick-Me-Up's, lower your stress level, re-balance your Happy Messengers, and enjoy life again.

ELIMINATE FOODS WHICH CAUSE BAD REACTIONS If a certain food makes you wheeze, or gives you a stuffy nose, or diarrhea, or red itchy bumps on your skin, you should obviously avoid that food. Any allergic reaction of this type is a stress on your body which will contribute to your OVERSTRESS.

There is another type of food reaction you should avoid. ANY FOOD THAT YOU CRAVE OR BINGE is a brain active food. You are craving or binging it because it is directly affecting your brain. Most of the time these are foods which contain the Pick-Me-Up's, sugar or caffeine. But sometimes the substance in the food is corn, milk, or yeast protein. Many people have sensitivity reactions to corn, milk, or yeast containing products. The protein in these substances directly affect brain messenger function. If, by this point in the book, you are STILL not feeling well, try a corn-free, milk-free and/or yeast-free diet. (Consult a dietician, or your doctor for a source of recipes).

VISIT A PROFESSIONAL COUNSELOR An experienced counselor can be of great help! It is often possible for a counselor to pinpoint stressors which you may have overlooked. Counselors can help you handle general life problems in ways that produce less stress. You should specifically seek instruction in cognitive therapy, assertiveness training,self-relaxation, biofeedback, and meditation. These techniques are very useful in reducing stress by teaching you how to "rest your mind." (For more information on types of counseling consult these links to some excellent web sites.) Places where you might find an experienced counselor: Referral from your doctor, your church, local hospital, community mental health program, or local college health service.

DISCUSS "BRAIN CHEMICAL RE-BALANCERS" WITH YOUR DOCTOR If, try as you might, you can not lower your stress levels enough to feel well, and if your doctor has found no hidden illness, then you might benefit from the use of a "brain chemical re-balancer". Over the last ten years, a type of medicine has been developed which is not a sleeping pill --yet it will help you sleep. It is not a stimulant -- yet it will give you energy. It is not a pain reliever -- yet it will diminish aches and increase your enjoyment of life. This family of non-addictive, prescription medicines works by re-balancing your brain's chemical messages.

Now, at this point you may be thinking, "But, Dr. Burns, you have pointed out the dangers of Pick-Me-Up's and Put-Me-Down's, how can you now recommend that we use a medication?" 

The answer is that these new brain chemical re-balancers, unlike the Pick-Me-Up's and Put-Me-Down's that we have mentioned, do not cause rebound (you don't have a quick upswing followed by a big crash), nor does one develop tolerance to them (you don't have to take more and more just to achieve the desired effect). They can be used to boost your Happy Messengers while you are in the process of lowering your stress load. And, if you are one of the persons who has inherited a very low stress tolerance, you may safely stay on these medications for a very long time.

You can view these medications the way we view insulin for the diabetic. The type I diabetic, try as he might, does not make enough insulin to handle his daily carbohydrate load. So he has to take insulin as a long term replacement medicine. If you have lowered your stress levels as much as you can, and if you have no hidden physical illness that is adding hidden stress to your life, and if you are still suffering from OVERSTRESS, you just may be an individual whose genetic inheritance does not allow you to make enough Happy Messengers to handle your daily stress load. You may indeed benefit from taking these brain chemical re-balancers as a long term replacement medicine, just as the diabetic benefits from insulin.

At present, there are quite a few of these medications that doctors can prescribe. They fall into two general categories, the "tricyclics" which variably boost serotonin, dopamine and noradrenalin; and the "selective serotonin reuptake inhibitors, or SSRI's" which act mainly to boost serotonin function. Both groups are equally effective, but they have different side effect profiles.Whether the doctor prescribes one group or the other depends mainly on what symptoms of overstress you are having.

Tricyclics Among the tricyclics are Amitriptyline, Nortriptyline, Imipramine, Desipramine, Clomipramine, Doxepin, and Trazodone (these are generic names). Some boost all the Happy Messengers, others boost Serotonin more than Dopamine or Noradrenalin. These rebalances will help you to sleep well, feel refreshed, and enjoy life. All the medicines have some side effects, but usually your doctor can help you select one that has very little in the way of side effects. (Usually the brain chemical re-balancers have much less side effects than the Pick-Me-Up's and Put-Me-Down's you may be presently using!)

To illustrate the way one uses tricyclic re-balancers, I will describe the use of Nortriptyline. Nortriptyline boosts all the Happy Messengers. (Brain chemical re-balancers MUST BE PRESCRIBED BY A PHYSICIAN after a careful medical history, physical examination, laboratory tests and EKG. PLEASE do not start or stop any prescription medicine without consulting your physician. The following information is intended to help you understand your doctor's instructions). Nortriptyline comes in a 25 mg pill. Most people should take one, two, or three pills of Nortriptyline, all together at bedtime. Each person requires a slightly different dose of Nortriptyline. Here is how to determine which dose is right for you.

The first night, you take 25mg of Nortriptyline at bedtime. If you have at least five to six hours of sound sleep and feel rested in the morning, then the dose needed to rebalance your brain chemistry is ONE Nortriptyline pill at bedtime. If you do not have at least five or six hours sound sleep, increase your dose to 50mg Nortriptyline the following night. If this gives you a restful sleep, then the dose necessary to balance your brain chemistry is TWO Nortriptyline at bedtime. If two does not result in a restful sleep, then the next night take 75mg at bedtime. Whether you need one, two, or three depends on how badly out of balance your brain messengers are. Obviously, the more you can reduce your stress load, the less Nortriptyline you will need to re-balance your brain chemistry.

PRECAUTIONS IN THE USE OF NORTRIPTYLINE Most people will feel somewhat DROWSY, or slowed down the FIRST WEEK that they are on Nortriptyline. THIS WILL PASS. But be careful when you drive a car, or operate machinery during this first week. From our discussion of shift work and jet lag, you will recall that it takes about three weeks to reset body rhythms. While they are resetting, you may feel somewhat lethargic. This is why we have you take the Nortriptyline at bedtime. After your body rhythms are reset, the Nortriptyline no longer causes drowsiness, but it continues to help keep your brain chemistry in balance.

By the way, if you are taking TOO MUCH Nortriptyline, you may have a very dry mouth, blurred vision, difficulty starting your urine stream, or rapid heartbeat. The very elderly may become confused. If any of these symptoms do occur, decrease your dosage and tell your doctor right away. Nortriptyline should not be used if you have a seizure disorder, glaucoma, certain heart diseases or thyroid disease. IF YOU ARE PREGNANT, OR LIKELY TO BECOME PREGNANT while takingthe Nortriptyline, do not take the Nortriptyline. It is not known if Nortriptyline, taken during pregnancy, causes adverse effects. Nortrityline can also stimulate appetite and lead to weight gain. Tricyclics can be dangerous if taken in massive overdose, so they are generally used with great caution in anyone that might have a tendency toward attempting suicide.

SSRI'S Fluoxetine (Prozac) is an example of an SSRI. It is a very effective re-balancer. Treatment with fluoxetine is begun with 20mg once in the morning. (10mg in elderly or frail individuals). In contrast to the tricyclics, fluoxetine tends to be energizing, cause weight loss, and stimulate the intestines. It may cause diarrhea or headache. It does not affect the heart conduction system, which makes it safer than tricyclics if a patient were to ingest a massive amount. From the different side effect profile, you can see fluoxetine is useful in someone who is depressed, lethargic, and out of energy. Nortriptyline is ideal for someone who can not fall asleep, wakes frequently, has panic attacks and diarrhea. Your doctor has many different re-balancers that can be prescribed. All are equally effective; each has a slightly different side effect profile. Work with your doctor. A little bit of patience, and you will find the one that re-balances you without any significant side effects.

Checklist for Handling Overstress REDUCE YOUR STRESS LOAD: --Reduce the pace of change in your life. --Reduce the social obligations. --Reduce work or school obligations. --Postpone changes in your living situation --Say "No" more often. --Eliminate possible food or environmental allergens. --Reduce environmental toxins.

GET OFF THE "ROLLER COASTER": --Diet: Take a multivitamin, mineral, trace element preparation; stabilize your blood sugar; eat more vegetables. --Exercise: Twenty minutes to two hours, three times a week. --Stop Your Pick-Me-Up's (consult your physician) --Stop Your Put-Me-Down's (consult your physician)

DO A "REST FOR YOUR MIND" ACTIVITY: --Exercise --Recreational reading, arts, crafts, music, --Dance --Meditation --Yoga --Biofeedback --Self-Hypnosis --Religious counseling HELP YOUR BODY CLOCK RE-SET ITSELF: --Set regular sleep times --Avoid time zone shifts or rapid changes in your work shift --Use daylight spectrum fluorescent lights to set your body clock's "awake time".

IF YOU JUST CAN NOT MAKE ENOUGH HAPPY MESSENGERS: --Have your doctor prescribe for you a brain chemical re-balancer

THREE RULES TO PERMANENTLY CONQUER OVERSTRESS

RULE ONE: LEARN TO READ YOUR BODY SIGNS Learn to check your body frequently for signs of OVERSTRESS. Watch for the telltale disturbances in your sleep pattern, as this is usually the earliest sign of OVERSTRESS. You must learn to read your body signs in much the same way as the diabetic learns the early warning signs of abnormal blood sugar. In order to cope successfully with diabetes, the diabetic has to learn to read his body's signals. If he has a constant thirst, fatigue and excessive urination, that means the sugar is too high. If he has shakiness, irritability, and perspiration that means the blood sugar is too low. In order to live with diabetes, the diabetic must understand what these signals mean. Likewise, if you are a person who is prone to OVERSTRESS, you must learn to look for its earliest warning signs. As soon as your sleep patterns change, or you experience fatigue, lack of enjoyment of life, anxiety, multiple aches and pains -- that is the time to go through the OVERSTRESS checklist.

RULE TWO: EXCHANGE YOUR STRESSES Keep your stress level below your individual OVERSTRESS point by "exchanging stresses". If a new stress comes into your life, then make room for it by eliminating or postponing another stress. This way, your TOTAL stress level remains low. The natural tendency is for people to let their stresses pile up rather than exchanging them. In this fashion, OVERSTRESS gradually occurs. With the development of OVERSTRESS, the person starts using more and more Pick-Me-Up's, taking off on the wild roller coaster of ill health. IN ORDER TO STAY HEALTHY LEARN TO EXCHANGE YOUR STRESSES

RULE THREE: USE YOUR TOOL BOX You now have a "TOOL BOX" full of ways to deal with your OVERSTRESS. Whenever your body shows signs of OVERSTRESS, you can use the tools from this book to help set yourself back on the path of well being. If you are feeling ill from OVERSTRESS, remember that the troubled sleep, fatigue, aches, lack of enjoyment of life, and panic attacks are caused by chemical changes in your brain. Effective treatment is available now. BEGIN TODAY!

EPILOGUE - HERE COMES ANOTHER PLAGUE Throughout history, mankind has had periodic episodes of illness which have decimated our population. The Bubonic Plague ravaged Europe in the Middle Ages. Syphilis killed one in four Europeans when it was introduced to Europe in the 1500's. Every other Hawaiian was killed by measles in the 1700's. Meanwhile, the Native Americans were slain by smallpox and other imported diseases.

Today, one in ten persons is falling victim to OVERSTRESS. Those who are becoming chemically dependent are walking a fatal path. Others "drop out" at an early age, to join the ranks of society's "marginal survivors".

The cost to society is immense. The effects of OVERSTRESS cost our society at least 60 billion dollars a year. Our society loses through: lost productivity, medical care for the complications of OVERSTRESS, job accidents, and traffic fatalities (half of which are related to driving while usingPick-Me-Up's). How can it be that one in every ten persons cannot physically adjust to the stress levels found in today's world? The answer lies in our society's pace of CHANGE.

FROM CARRIAGE TO ROCKET SHIP We certainly live in a society whose hallmark is rapid change. Our broader definition of stress tells us that this rapid change means high stress levels. Most of the human experience on Earth has not involved such a rapid pace of change. Most of the human experience has not prepared us to handle the demands of 20th Century life. That is why one in ten persons is constantly fighting OVERSTRESS.

Let us step outside our present time to see this more clearly. In the state of Utah, near the Great Salt Lake, is an archeological site known as "Danger Cave". Excavation at this site shows a record of human habitation extending back ten thousand years. This record shows that four hundred generations of persons lived basically the same life style and used basically the same tools. Generation upon generation faced similar life conditions, made subtle changes from season to season, and from year to year.

Ways of solving each of life's problems were accumulated in the knowledge of the village elders and religious leaders. This knowledge was then passed from generation to generation. Change, when it did come, occurred over millennia. A people who hunted with spears learned to use spearthrowers to increase their accuracy -- time elapsed: perhaps 5,000 years. Bows and arrows greatly increased the accuracy and ease of hunting -- time elapsed: perhaps 4,000 more years. Agriculture was developed. In this case, the growing of maize as a crop -- time elapsed: perhaps 2,000 more years.

A future archeological excavation of Salt Lake City would show a gigantic upheaval occurring around 1900 A.D. After ten thousand years of snail paced change, the future arrived precipitously. During the course of a single lifetime, a person born in 1900 A.D. has seen the advent of radio, television, computers, automobiles, motorcycles, propeller airplanes, jet aircraft, space ships, a moon landing, test tube babies, two wars which involved the entire Earth in conflict, nuclear power generation, and nuclear weapons.

In this environment, the elder generation can no longer be assured of having the "right answer" to every problem. Life is changing radically within the space of even one generation. Today's society has shifted from being elder dominated, where the solutions to life's problems are passed down by the elders, to a "youth culture", where flexibility and adaptability to change are vital if one is to "stay on top of" a continuously changing life. Survival in society today requires more flexibility and adaptability than every before in human history. All the preceding years of human existence have not prepared us physically for such a grueling pace of change. One in ten persons is already dropping by the wayside, yet the pace accelerates unabated. Twenty First Century humans will have to maintain physiologic balance in an increasingly stressful sea of technological and cultural changes. Luckily, an understanding of the problem is emerging which is enabling us to help those with Low Stress Tolerance. As society stress levels continue to rise, we will all need to recognize and counter the effects of -- OVERSTRESS.