Preventative Medicine

Preventative Medicine

[vc_row][vc_column width=”1/1″][vc_toggle title=”Information for Travelers to Pakistan ” state=”open”]
Pakistan, with an estimated population of 140 million stands as one of the most populous country of the world. Its annual growth rate is 2.3%. The population density of the country as a whole is 163 persons per sq. km. Fifty one percent of the population is male. Climate is generally arid; hot summers, cool or cold winters.

Although there has been increased attention paid to the rights of women and children, much work continues to be done in this area to achieve the desired outcomes. Basic education, population, health and nutrition indicators are far below the desired levels and they are not at par with regional and international standards. The social sector indicators of the country are not encouraging and especially in rural areas and less developed urban areas still cause great concern to all national and international agencies. The infant mortality rate of approximately 86 per 1,000 births is comparatively high for a country with the overall state of economic development like Pakistan. Maternal mortality rate vary from 350 to 450 per 100,000 live births. Substandard housing, inadequate sanitation and water supply, and widespread malnutrition contribute to spread of disease and to high infant, childhood, and maternal mortality. Leading causes of death are gastroenteritis, respiratory infections, tuberculosis, malaria, and typhoid fever.

In health sector about 30 % of the out patient health services are provided through Public sector and the remaining health care is done by the private sector. It is reverse in case of in-patient services. Private sector involvement in the planning of health care is almost negligible and there are no linkages available between public sector health care delivery and the private sector. NGOs are working independently with minimal coordination with government or private sector (for profit). The overall literacy rate estimated at more than 36 percent for adult population. Literacy rates substantially lower for women and more marked in the women of rural and under developed urban slums. Urdu is the official language, but English in general use in government, military, business, and higher education. About 97 percent of Pakistanis are Muslim, 77 percent of whom are Sunnis and 20 percent Shia; remaining 3 percent of population divided equally among Christians, Hindus, and other religions.

Food and waterborne diseases are the number one cause of illness in travelers. Viruses, bacteria or parasites can cause traveler’s diarrhea, which are found throughout the country. Food and water may be contaminated with E. coli, Salmonella and different types of parasites. Hepatitis is also widely spread and is another risk to take unprotected food and water. It is advisable to make sure your food is properly cooked and fresh and always use the boiled/filtered water.

Another safety measure is to take canned carbonated drinks, ALWAYS avoid the “so called” mineral water.

Malaria is also quite prevalent in Pakistan. Plasmodium Falciparum and Vivax are prevalent in Pakistan. Malaria is a preventable infection that can be fatal if left untreated. Taking standard anti malarial prescriptions can prevent malaria infection. It is advisable to use mosquito repellants and protect yourself against mosquito bites. The pregnant women has to be extra cautious about malaria, better avoid travel during pregnancy to any malaria risk country and if one needs to travel you must contact your physician for advice. (If you have visited a malaria-risk area, continue taking your anti malarial drug for 4 weeks after leaving the risk area. Travelers who become ill with a fever or flu-like illness while traveling in a malaria-risk area and up to one year after returning home should seek prompt medical attention and should tell the physician their travel history). If you plan to visit the mountains in northern areas, ascend gradually to allow time for your body to adjust to the high altitude, which can cause insomnia, headaches, nausea, and altitude sickness. In addition, use sun block, because the risk of sunburn is greater at high altitudes. Protecting you against insect bites will help to prevent diseases like Dengue, Filariasis, Encephalitis and Leishmaniasis. Though these diseases are rare but one needs to be careful. Because motor vehicle crashes are a leading cause of injury among travelers, walk and drive defensively. Avoid travel at night if possible and always use seat belts.

There is no risk for yellow fever in the Pakistan. A certificate of yellow fever vaccination may be required for entry into Pakistan if you are coming from countries in South America or sub-Saharan Africa.

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[vc_toggle title=”Recommended Vaccines (according to age group) ” ]
Please consult the Preventative clinic at least 1 month before you plan your visit to Pakistan, because usually 2-4 weeks are required for any vaccine to be effective.

Following are the recommended vaccines:

Hepatitis A immunoglobulin (IG).
Hepatitis B, if your visit needs exposure to health work or to be exposed through medical treatment.
Typhoid vaccination is important because of the presence of S. typhi stains resistant to multiple antibiotics in the country.
As needed, booster doses for Polio, DPT (Diphtheria, Pertusis and Tetanus), and Measles according to age of the traveler. It may be reminded that though Pakistan is in the process of eradicating Polio but still it is one of the major countries where Polio reported cases are maximum.

National EPI Program Has recently included Hepatitis B and C in its routine Immunization Program. Some TIPS to remain healthy during your stay in Pakistan:

Wash hands often with soap and clean water.
Drink only boiled/filtered water, or carbonated drinks in cans or bottles.
Avoid tap water, fountain drinks, and ice cubes.
Eat only thoroughly cooked food or fruits and vegetables you have peeled yourself. Remember: boil it, cook it, peel it, or forget it.
Don’t eat food purchased from street vendors.
If you are going to visit areas where there is risk for malaria, take anti malarial (as prescribed by your physician) before, during, and after travel, as directed.
Protect yourself from insects by remaining in well-screened areas, using repellents and wearing long-sleeved shirts and long pants from dusk through dawn.
To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot.
Always use condoms to reduce the risk of HIV and other sexually transmitted diseases.
Don’t eat dairy products unless you know they have been pasteurized.
Don’t handle animals (especially monkeys, dogs, and cats), to avoid bites and serious diseases (including rabies and plague).
Don’t swim in fresh water. Salt water is usually safer.

Please take following with you during your visit To Pakistan

Long-sleeved shirt and long pants to wear while outside whenever possible, to prevent illnesses carried by insects.
Insect repellent.
Over-the-counter anti diarrhea, anti pyretic medicines to take if you have diarrhea or fever.
Iodine tablets and water filters to purify water.
Sun block, sunglasses and hat.
Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s).

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[vc_toggle title=”Food And Water Borne Infections ” ]
Contaminated food and drink are common sources for the introduction of infection into the body. Among the more common infections that one can acquire from contaminated food and drink are Escherichia coli infections, shigellosis or bacillary dysentery, giardiasis and hepatitis A.

Other less common infectious diseases spread by food and contaminated water are: typhoid fever and other salmonella infections, cholera and viral infections like rotavirus infections. One of the most common infections found in Pakistan due to infected water is the helminthic infestation in children. Many of the infectious diseases transmitted in food and water can also be acquired directly through the fecal-oral route.

Water

Water that has been adequately chlorinated, using minimum recommended water treatment standards (WHO standards) employed in developed countries, does provide significant protection against viral and bacterial infections. However, chlorine treatment alone may not protect the population against enteric viruses and the parasitic organisms that cause giardiasis and amebiasis. In areas where tap water is not available or where hygiene and sanitation are poor, it is advised that people should only use following:

Sufficiently boiled water with proper storage.
Beverages, such as tea and coffee, made with boiled water.
Carbonated beverages (soft drinks) like Coke, 7Up & PEPSI etc. in Pakistan it is advisable not to trust the bottled water because one is never sure about the quality control.

Treatment of water

Following methods may be used to treat water to make it safe for drinking and other purposes.

Boiling is by far the most reliable method to make water of uncertain purity safe for drinking. Water should be brought to a vigorous rolling boil for 1 minute and allowed to cool to room temperature; ice should not be added. This procedure will kill bacterial and parasitic causes of diarrhea at all altitudes and viruses at low altitudes. To kill viruses’ water should be boiled for 3 minutes or chemical disinfection should be used after the water has boiled for 1 minute. Adding a pinch of salt to each quart or pouring the water several times from one clean container to another will improve the taste.
Chemical disinfection with iodine is an alternative method of water treatment when it is not feasible to boil water. However, this method cannot be relied upon to kill Cryptosporidium unless the water is allowed to sit for 15 hours before it is drunk. Two well-tested methods for disinfection with iodine are the use of tincture of iodine and the use of tetraglycine hydroperiodide tablets (for example, Globaline, Potable-Aqua, or Coghlan’s). The manufacturers’ instructions should be followed. If water is cloudy, the number of tablets used should be doubled; if water is extremely cold, an attempt should be made to warm the water, and the recommended contact time should be increased to achieve reliable disinfection. Chlorine, in various forms, can also be used for chemical disinfection. However, its germicidal activity varies greatly with the pH, temperature, and organic content of the water to be purified and, therefore, it can produce less consistent levels of disinfection in many types of water. It may be noted that chemically treated water is intended for short-term use only. If iodine-disinfected water is the only water available, it should be used for only a few weeks to avoid goiter. One should be extremely careful to use iodine treated water in the mountainous part of the country.
Portable filters currently available in the market provide various degrees of protection against microbes. Reverse-osmosis filters provide protection against viruses, bacteria, and protozoa, but they are expensive, are larger than most filters used by backpackers, and the small pores on this type of filter are rapidly plugged by muddy or cloudy water. In addition, the membranes in some filters can be damaged by chlorine in water. Micro-strainer filters can remove bacteria and protozoa from drinking water, but they do not remove viruses. To kill viruses while using micro-strainer filters one should disinfect the water with iodine or chlorine after filtration, as described previously. Filters with iodine-impregnated resins are most effective against bacteria, and the iodine will kill some viruses; however, the contact time with the iodine in the filter is too short to kill the protozoa.
As a last resort, if no source of safe drinking water is available or can be obtained, tap water that is uncomfortably hot to touch might be safer than cold tap water; however, proper disinfection, filtering, or boiling is still advised.

Food

If some body is not careful food can be the source to get infection. All raw foods are subject to contamination, particularly in areas where hygiene and sanitation are inadequate. It is always advisable to avoid fresh salads, uncooked vegetables, and open milk and milk products. While eating, especially in summer one should eat food, which is properly cooked and is still hot, or fruit that has been peeled by clean hands. Undercooked and raw meat, fish, and shellfish can carry various intestinal pathogens. Cooked food that has been allowed to stand for several hours at ambient temperature can provide a fertile medium for bacterial growth and should be thoroughly reheated before serving. Consumption of food and beverages obtained from street food vendors may be associated with an increased risk of illness. Infants, younger than 4 months of age should at all cost be fed by breast milk.

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[vc_toggle title=”Expanded Program of Immunization (EPI) ” ]
Immunization Schedule is carried under EPI. EPI is a WHO and UNICEF assisted program. The following plan is carried out in children according to EPI:
Age Vaccine Dose Route of Administration
At Birth Bacille Calmette Guerin (B.C.G)
Oral Polio Vaccine(OPV) 0.5ml
3 Drops Intra-dermal
Oral
6 Weeks DPT mixture of diphtheria, pertussis, and tetanus
OPV 0.5ml
3 Drops I/M
Oral
10 Weeks DPT
OPV 0.5ml
3 Drops I/M
Oral
14 Weeks DPT
OPV 0.5ml
3 Drops I/M
Oral
9 Months Measles 0.5ml I/M
15 Months MMR mixture of measles, mumps and rubella 1ml I/M
1st Booster
(18 months) DPT
OPV 0.5ml
3 Drops I/M
Oral
2nd Booster
(5 years) DPT
OPV 0.5ml
3 Drops I/M
Oral
Immunization in Pregnant Women

Tetanus Toxoid 2 Doses are given 4 weeks apart. Dose is 0.5ml. and given I/M. It is now recommended that 1st. dose is given after 12 weeks of pregnancy and 2nd. Dose is given 4 weeks after 1st. Dose. When 2 nd. Pregnancy occurs within 5 years of first pregnancy only 1 dose 0.5ml. given after 12 weeks of pregnancy is required. It is now recommended that Children should be immunized against Hepatitis B. After 1 week of birth, Hepatitis B vaccine Mini dose is given. Second dose is repeated again after 1 month, third dose is again after 1 month. Booster dose is given 1 year after the first dose.
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[vc_toggle title=”Acquired Immune Deficiency Syndrome (AIDS) ” ]
AIDS is a specific group of diseases or conditions that result from suppression of the immune system related to infection with the human immunodeficiency virus (HIV). A person infected with HIV gradually loses immune function along with certain immune cells, called CD4 T-lymphocytes or CD4 T-cells, causing the infected person to become vulnerable to pneumonia, fungus infections, and other common ailments. With the loss of immune function, a clinical syndrome (a group of various illnesses that together characterize a disease) develops over time and eventually results in death due to opportunistic infections (infections by organisms that do not normally cause disease except in persons whose immune system has been greatly weakened) or cancers.

Infection with HIV does not necessarily mean that a person has AIDS, although people who are HIV-positive are often mistakenly said to have AIDS. In fact, a person can remain HIV-positive for more than ten years without developing any of the clinical illnesses that define and constitute a diagnosis of AIDS. In 1995 an estimated 18.4 million people worldwide were living with HIV or AIDS. The World Health Organization estimates that between 1981, when the first AIDS cases were reported, and the end of 1995; over 6 million adults and children had developed AIDS.

Clinical Progression of AIDS

The progression from the point of HIV infection to the clinical disease that define AIDS may take six to ten years or more.

Acute Retroviral Syndrome: Within one to three weeks after infection with HIV, most people experience nonspecific flu like symptoms such as fever, headache, skin rash, tender lymph nodes, and a vague feeling of discomfort. These symptoms last about one to two weeks. During this phase, known as the acute retroviral syndrome phase, HIV reproduces to very high concentrations in the blood, mutates (changes its genetic nature) frequently, circulates through the blood, and establishes infections throughout the body, especially in the lymphoid organs. The infected persons CD4 T-cell count falls briefly but then returns to near normal levels as the persons immune system responds to the infection. Individuals are thought to be highly infectious during this phase.
Asymptomatic Phase: A symptom-free phase that can last ten years or more. Persons with HIV remain in good health during this period, with levels of CD4 T-cells ranging from low to normal (500 to 750 cells per cubic mm of blood). Nevertheless, HIV continues to replicate during the asymptomatic phase, causing progressive destruction of the immune system.
Early Symtomatic Phase: This phase can last from a few months to several years and is characterized by rapidly falling levels of CD4 T-cells (500 to 200 cells per cubic mm of blood) and opportunistic infections that are not life threatening.
Late Symtomatic Phase: It is characterized by the extensive immune destruction and serious illness. This phase can also last from a few months to years, and the affected individual may have CD4 T-cell levels below 200 per cubic mm of blood along with certain opportunistic infections that define AIDS. A wasting syndrome of progressive weight loss and debilitating fatigue occurs in a large proportion of people in this stage.
Advanced AIDS Phase: In this CD4 T-cell numbers are below 50 per cubic mm of blood. Death due to severe life-threatening opportunistic infections and cancers occurs within one to two years.

Human Immunodeficiency Virus (HIV)

The causative agent of AIDS is HIV, a human retrovirus. Researchers have known since 1984 that HIV enters human cells by binding with a receptor protein known as CD4, located on human immune-cell surfaces. HIV carries on its surface a viral protein known as gp120, which specifically recognizes and binds to the CD4 protein molecules on the outer surface of human immune cells. However, in 1984 researchers found that CD4 by itself was not sufficient for HIV infection to take place. Some other unknown factor, found only in human cells, was also required. After much research, in 1996 scientists discovered a protein on the surface of human immune cells that together with CD4 permits human immune cells to fuse with HIV’s surface protein, gp120, a key step in the infection process. This newly discovered human immune-cell surface protein has been named fusin.
Modes of Transmission

HIV spreads through the exchange of body fluids, primarily semen, blood, and blood products. It is most commonly spread by sexual contact with an infected person. The virus is present in the sexual secretions of infected men and women and gains access to the bloodstream of the uninfected person by way of small abrasions that may occur as a consequence of sexual intercourse.

HIV is also spread by any sharing of needles or syringes that result in direct exposure to the blood of an infected individual. This method of exposure occurs most commonly among people abusing intravenous (IV) drugs and or blood transfusion.

HIV can be transmitted from an infected mother to her baby, either before or during childbirth, or through breastfeeding. Although only about 20 to 30 percent of babies born to HIV-infected mothers actually become infected, this mode of transmission accounts for 90 percent of all cases of AIDS in children. In addition, even uninfected children born to HIV-infected mothers have an incidence of heart problems 12 times that of children in the general population.

In the health-care setting, workers have been infected with HIV after being stuck with needles containing HIV-infected blood or, less frequently, after infected blood contacts the workers open cut or splashes into a mucous membrane (for example, the eyes or the inside of the nose). There has been only one demonstrated instance of patients being infected by a health-care worker; this involved HIV transmission from an infected dentist to six patients. In general, infected health-care workers pose no risk to their patients. There is also no risk of contracting HIV infection while donating blood.

Infections are NOT trasmitted by the following Actions

Casual contact in a household, school, workplace, or food-service setting.
Drying of HIV-infected human blood or other body fluids reduces the theoretical risk of environmental transmission to essentially zero. Additionally, HIV is unable to reproduce outside its living host; therefore, it does not spread or maintain infectiousness outside its host.
No cases of HIV transmission through the air, by casual contact, or even by kissing an infected individual have been documented. Researchers have recently identified a protein in saliva, known as secretary leukocyte protease inhibitor (SLPI) that prevents HIV from infecting white blood cells. However, practices that increase the likelihood of contact with the blood of an infected individual, such as open-mouth kissing or sharing toothbrushes or razors, should be avoided.

Detection and Diagnosis

Although AIDS has been tracked since 1981, the identification of HIV as the causative agent was not made until 1983. In 1985 the first blood test for HIV, developed by the research group led by Robert Gallo, was approved for use in blood banks. This test can detect whether a persons blood contains antibodies against HIV, an indication of exposure to the virus. However, for about four to eight weeks after exposure to HIV, an individual will continue to test negative for HIV infection because the immune system has not had enough time to make antibodies against HIV. In 1996 an additional blood test was approved for use in blood banks. This test can detect HIV antigens-proteins produced by the virus itself. The test c an thus identify HIV even before the donor’s immune system has had a chance to make antibodies.
Treatment

Antiviral drugs that attack HIV
Treatment for AIDS-associated opportunistic infections
Drug treatments for PCP
Anti fungal drugs like amphotericin B and fluconazole are effective against AIDS-related fungal infections
The antiherpes drugs ganciclovir and foscarnet are used to treat CMV retinitis and other herpes diseases
Bone marrow xenotransplantation
Gene therapy
Immunization: Efforts also are under way to develop an effective immunization that could be protective, preventing infection if an immunized person is exposed to HIV, or therapeutic, prolonging survival or decreasing immune destruction in people already infected with HIV. The World Health Organization (WHO) is currently sponsoring a large-scale trial of a protective-vaccine candidate in areas of the world where the rate of HIV infection is just beginning to rise dramatically.

Prevention Efforts:

Fortunately all forms of HIV transmission are preventable. The strategies for prevention and control can be divided into:
Prevention of Sexual Transmission:

The AIDS is a sexually transmitted disease. Public health education must stress this fact and the necessity to refrain from sexual relations outside marriage. In this region efforts should be made to benefit from the strong religious beliefs in promoting healthy life styles and refraining from unhealthy ones, including promiscuous sexual relations. Infected persons should be advised on methods of safer sex such as the use of condoms, which significantly reduces the probability of transmission of infection. National programs should ensure the availability and accessibility to condoms.
Prevention of Blood Borne Transmission:

Following precautions must be taken to avoid transmission through blood:

Avoiding blood transfusion if not seriously needed.
Screening of blood and blood donors.

If blood cannot be screened, ways to exclude donors with higher risks for AIDS have to be considered, through:

Voluntary self-exclusion systems in which persons practicing risky behaviors refrain from giving blood. This may be achieved through donor education.
Obtaining the history of possible exposure to a known risk as well as enquiring about suggestive symptoms such as chronic diarrhea, and weight loss. Physical examination of the donor should be encouraged because it can identify unusual mucosal or skin lesions, lymphadenopathy or wasting.

Prevention of Transmission through Injection

Instruments used for injections and other skin piercing instruments, such as lancets for taking blood drops for laboratory examination of blood, ear piercing and tattooing are safe and not contaminated.
Prevention of Perinatal Transmission

Infected women should be advised against pregnancy. A recent study demonstrated that zidovudine (AZT) administration to a selected group of HIV infected pregnant women and their infants can reduce the risk of perinatal transmission by two third.
Situation in Pakistan

Pakistan has an estimated population of 152,331 thousand in 1999. Its annual growth rate is 2.7%. The proportion of males in the population is 51.6%. Pakistan has experienced a modest but steady economic growth since the early 1990s but the health indicators are relatively low. There has also been a socio-economic positive change with increased awareness of rights of women and children and the importance of community involvement in development efforts is widely acknowledged. The major determinants of health in the country are socio-economic conditions, literacy rates, life styles, water supply and sanitation, environmental conditions, rapid population growth rate and availability of good quality health care services. Basic population, health and nutrition indicators do not depict a happy picture.

The overall situation regarding the health status of children, youth and women in Pakistan especially in rural areas and less developed urban areas still causes great concern to all national and international agencies. The infant mortality rate of approximately 86 per 1,000 births is comparatively high for a country with the overall state of economic development like Pakistan. Figures quoted for maternal mortality rate vary from 350 to 450 per 100,000 live births and are among the highest in the region. Main causes of morbidity and mortality are T.B, Diarrhea, ARI, mal-nutrition and preventable diseases. HIV/AIDS is one of the threats to the health authorities in the country.

With regards to HIV/AIDS, Pakistan is one of the low reporting countries` in the world. The first case of AIDS was reported in 1987. The National AIDS Program (NAP) of the Government of Pakistan (GOP) officially reports a cumulative total of 1462 HIV + cases and 190 AIDS cases with an estimated prevalence of 0.07% as of March 2000, whereas WHO – Epi-modle estimations are about 70-80 thousand HIV positive cases. Pakistan is considered as low prevalence and high risk in terms of HIV/AIDS.

The risk factors are not much different from other societies in the globe and they are:

Intravenous drugs abuse
Absence of universal blood screening
Commercial and unprotected sex
Hazardous hospital waste
Low condom use rates

The vulnerable conditions, which lead to high-risk behavior, are: –

Power and status imbalances between men and women
Young Peoples vulnerability because of traveling, exposure etc
Patterns of labor migration both within and outside of the country
Low education and literacy levels (especially among women)
Poor Socioeconomic conditions
Weak health care systems

National AIDS Control Program (NACP)

National AIDS Program is one of the five major public health programs under the umbrella of Ministry of Health, Government of Pakistan. Since its inception it is based at National Institute of Health Islamabad. Being the focal point for the prevention of activities pertaining to HIV / AIDS it is relevant to enumerate its policies and actions:

Information, education and communication for the general public and focused groups.
Provision of HIV screened blood to the population at large.
Provide care, support and counseling for HIV positives and AIDS patients.
Prevention and management of sexually transmitted infections.
Strengthen the component of program management.

National AIDS Control Program (NACP) was initially started with the formation of Federal Committee on AIDS (FCA) in August 1987. FCA devised broad policy guidelines and defined Preventative and control measures and coordinates with international agencies. The National Institute of Health (NIH) was assigned to implement the National AIDS Prevention and Control Program. National AIDS Control Program is focusing on following General and Specific Objectives: General Objectives:

To prevent HIV transmission.
To reduce morbidity associated with HIV/AIDS.
To promote safe blood transfusion and safe sexual behavior.
To interrupt STD transmission.
To establish an AIDS surveillance and monitoring system.
To conduct training of various categories of health staff
To conduct research and social behavioral studies.
To further develop and strengthen a program management structure at Federal and Provincial/Area levels.

Specific Objective

To create awareness through information, education and communication.
To prevent the spread of HIV/AIDS through ensuring safe blood transfusion and aseptic practices.
To strengthen STD services and to provide effective STD case management.
To provide clinical counseling, home care and management.
To establish surveillance and monitoring of the program progress, its impact and evaluation.
To conduct training for various categories of Health Staff.
To conduct research in social behavior studies through effective intervention activities and involvement of community and NGOs.
To develop and strengthen program management structure, provide technical assistance and coordination activities at federal and provincial level.

National AIDS Control Program (NACP) main focus is to prevent and control of HIV/AIDS in the country. The Program is focusing to achieve above-mentioned objectives. The main components of the program are:

Information, Education and Communication
Safe Blood Transfusion
Sexually Transmitted Diseases: (STDs)
Case Management, Counseling and Home Care
Surveillance and Monitoring
Training
Research
Program Management

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[vc_toggle title=”Scabies” ]
Scabies is an infestation of the skin with the microscopic mite Sarcoptes scabies. Infestation is common, found worldwide, and affects people of all races and social classes. Scabies spreads rapidly under crowded conditions where there is frequent skin-to-skin contact between people, such as in hospitals, institutions, child-care facilities, and nursing homes. It is characterized by itching on the body and is most common in our country in children and young adults, but may occur at any age

Scabies is more common in overcrowding, which is common in rural areas and city slums and is almost invariably associated with poverty and poor hygiene. It is usually transmitted by direct, prolonged, skin-to-skin contact with a person already infested with scabies. Contact must be prolonged (a quick handshake or hug will usually not spread infection). Infestation is easily spread to sexual partners and household members. Infestation may also occur by sharing clothing, towels, and bedding. For a person who has never been infested with scabies, symptoms may take 4-6 weeks to begin. For a person who has had scabies, symptoms appear within several days. You do not become immune to an infestation.

Mite is very sensitive to open environment and once it is away from the human body, it does not survive more than 48-72 hours. When living on a person, an adult female mite can live up to a month. Pets become infested with a different kind of scabies mite. If your pet is infested with scabies (also called mange) and they have close contact with you, the mite can get under your skin and cause itching and skin irritation. However the mite dies in a couple of days and does not reproduce. The mites may cause you to itch for several days, but you do not need to be treated with special medication to kill the mites. Until your pet is successfully treated, mites can continue to burrow into your skin and cause you to have symptoms.

People with weakened immune systems and the elderly are at risk for a more severe form of scabies, called Norwegian or crusted scabies.

Causal Agent

Sarcoptes scabies, human itch or mange mites, are in the arthropod class Arachnida, subclass Acari, family Sarcoptidae. These mites burrow under the skin, living in linear burrows. Other races of scabies may cause infestations in other mammals such as domestic cats, dogs, pigs, and horses. It should be noted that races of mites found on other animals cannot establish infestations in humans. They may cause temporary itching due to dermatitis but they do not tunnel into the skin.
Life Cycle of Sarcoptes scabies

Mode of transmission is primarily person-to-person contact. Newly emerged impregnated females will crawl onto the uninfected person. The mite will hold onto the skin using suckers attached to the two most anterior pairs of legs. They will then burrow into the skin. Transmission may also occur via fomites (e.g., bedding or clothing). Sarcoptes scabies undergoes four stages in its life cycle; egg, larva, nymph and adult. Sarcoptic mites form definite burrows under the skin in which females deposit eggs. Females deposit eggs at 2 to 3 day intervals as they burrow through the skin. Eggs are oval and 0.1 to 0.15 mm in length. Incubation time for eggs is 3 to 8 days. After the eggs hatch, the mites migrate to the skin surface and molt. The larval stage, which emerges from the eggs, has only 3 pairs of legs. This form lasts 2 to 3 days. After larvae molt, the resulting nymphs have 4 pairs of legs. This form molts into slightly larger nymphs before molting into an adults. Larvae and nymphs may often be found in short burrows or hair follicles. They look similar to adults, only smaller. Adults are round, sac-like eyeless mites. Females are 0.3 to 0.4 mm long and 0.25 to 0.35 mm wide. Males are slightly more than half that size. Mating occurs on the skin surface. Afterward, the impregnated female will burrow into the skin and spend the remaining 2 months of her life in tunnels under the surface of the skin. Males are rarely seen. They make a temporary gallery in the skin before mating.
Clinical Features:

Itching is usually the most obvious manifestation of scabies. It is generally worst at night and when the patient is warm. The onset occurs 3-4 weeks after the infection is acquired and coincides with a widespread eruption of inflammatory papules. Some of the features are as follow:

Pimple-like irritations, burrows or rash of the skin, especially the webbing between the fingers; the skin folds on the wrist, elbow, or knee; the penis, the breast, or shoulder blades.
Intense itching, especially at night and over most of the body.
Sores on the body caused by scratching. These sores can sometimes become infected with bacteria.

The diagnostic lesions of scabies are burrows. Which appear as slightly raised, brownish, tortuous lesions. The point of entry of the mite, the most superficial part of the burrow, has a slightly scaly appearance, and at the distal end there may be vesicle. In the patient with high standard of hygiene they may be difficult to find. They may occur on the wrists, the borders of the hands, the sides of the fingers and the finger web spaces, the feet, particularly the instep and, in the male, the genitalia. Head and neck area can be involved in the babies.
Diagnosis

Looking at the burrows or rash most commonly makes diagnosis. A skin scraping may be taken to look for mites, eggs, or mite fecal matter to confirm the diagnosis. If a skin scraping or biopsy is taken and returns negative, it is possible that you may still be infested. Typically, there are fewer than 10 mites on the entire body of an infested person; this makes it easy for an infestation to be missed.
Laboratory Diagnosis

Mostly diagnosis of scabies is based upon the appearance and distribution of the rash and the presence of burrows. Whenever possible scabies should be confirmed by isolating the mites, ova in a skin scraping. Scrapings should be made at the burrows, especially on the hands between the fingers and the folds of the wrist. Alternatively, mites can be extracted from a burrow by gently pricking open the burrow with a needle and working it toward the end where the mite is living.
Treatment

Several lotions are available to treat scabies. Apply lotion to a clean body from the neck down to the toes and left overnight (8 hours). After 8 hours, take a bath or shower to wash off the lotion. Put on clean clothes. All clothes, bedding, and towels used by the infested person 2 days before treatment should be washed in hot water; dry in a hot dryer. A second treatment of the body with the same lotion may be necessary 7-10 days later. Anyone who is diagnosed with scabies, as well as his or her sexual partners and persons who have close, prolonged contact to the infested person should also be treated. All the family members should receive treatment at the same time to prevent re-infestation.

Pregnant women and children are often treated with milder scabies medications. Following are the different medicines used for the scabies are as follows:

Sulphur
Benzyl benzoate
Malathione
Permetharin
Gamma benzene hex chloride (lindane)
Topical thiabendazole and crotamiton
Ivermectin

Treatment of Infants & Young Children

Benzyl benzoate can be diluted with 2-3 parts of water if used on infants and young children.
Institutional Outbreaks of Scabies

There are numerous reports of outbreaks affecting both patients and medical personnel in hospitals and residential homes. Nursing and medical staff in contact with patient may develop the common type of scabies but frequently the first lesions seen are pruritic papules on the limbs without clinical evidence of burrows.

In this situation all the patients or residents should be examined t o detect any cases of severe or crusted scabies that may require several treatments, otherwise the problem may persist in spite of adequate treatment.
Any patient with crusted scabies should be isolated until cured.
Any personnel coming into contact with such a patient should wear long sleeved gowns and gloves.
All individuals in an affected ward or in a residential home and all medical and nursing staff and their families should be treated with a scabicide.
Bedding should be laundered.
It has been suggested that during treatment of institutional.

out breaks particular attention should be paid to the nails as mites
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