Posts Tagged ‘WHO’

Tetanus: it hasn't disappeared, even here..

Monday, June 24th, 2013

We were at a fiftieth wedding anniversary party on a weekend night and ate, among other things, baked beans and chocolate cupcakes. So when I saw a dark splotch on a friend's arm I thought he'd spilled something on himself.

A rusty sharp piece of metal poises several dangers

A rusty sharp piece of metal poises several dangers

He said, "No, I scratched myself this morning on a rusty piece of metal."

"When did you have your last tetanus booster?"

"You know, I don't remember"

His physician is in solo practice and my friend was unsure of his weekend coverage, so I suggested going to the Urgent Care Clinic our local hospital runs. I nudged him buy showing a 1807 painting of a men with opisothonus, the most extreme muscle spasm one can imagine. At that point he showed me his contact information for his internist and I dialed the number and handed the phone back to him.

As it turned out his doc answers his own messages and told his patient that he had had boosters, but would check his record on the following Monday morning and then call him.

So why was I concerned? After all, the number of cases of tetanus, also called lockjaw, is very small in the United States, usually less than 40 to 60 a year.

That statement holds for most developed countries, but certainly not for the rest of the globe.

Worldwide it's quite a different matter with one source noting over 14,000 cases reported in 2011 and a 5-year death toll of 81,000 reported in 2008.

Still, that's a marked improvement over past years when estimates of a million deaths a year, mostly in Africa and Asia, were the rule. In the late 1980s the World Health Organization (WHO) estimated 787,000 newborns died of neonatal tetanus (NT). That's about 6.7 per every 1,000 live births.

The WHO has an ongoing campaign to eliminate maternal and neonatal (newborn) tetanus and by 2101 the number of NT deaths was estimated at 58,000, still enough souls to fill a mid-sized community, but 93% less than slightly over 20 years previous.

Yes, but a significant number of those who do get it die and having a dirty wound is clearly a risk factor for tetanus.

The tetanus bacteria, an anaerobic (capable of living without oxygen) rod-shaped organism, is found in soil and in the gut flora (the mass of bacteria living in the intestines) of animals and humans. Overall our bowels carry 100 trillion microorganisms, ten times a many as the entire number of cells in a human, with estimates of a hundred times the number of genes as our human genome possesses.

It is not transmitted from person to person, but is present throughout the environment and is commonly found in soil contaminated with manure, and animal and human feces. The incubation period is usually 7 to 8 days, but can range from 3 days to three weeks with shorter incubation timing being associated with heavily contaminated wounds.

Tetanus often begins with muscular stiffness in the jaw, e.g., lockjaw, followed by stiffness in the neck, difficulty swallowing, rigidity of the abdominal muscles, spasms, sweating and fever. Other complications can include vocal cord and/or repsiratory muscle spasm. In especially severe cases long bone or spine fractures can occur as a result of muscle spasms.

The Mayo Clinic's article on tetanus agrees that the tetanus vaccine has made the disease quite rare in developed countries, but notes there are still somewhere about a million cases every year elsewhere in the world (that's quite different from the number I mentioned above, but may represent older figures). There is no cure for this terrible disease and fatality rates, which used to range from 48% upward, are still close to 10% even in settings where modern supportive therapy is available. That may include antibiotics, bed rest in an environment with lights dimmed, noise kept at a minimum and temperature stabilized, drugs for muscle relaxation, sedation and debridement (localized surgery to clean the wound) & possibly tetanus immune globulin.

If no treatment is given, roughly 25% of those infected die and those rates are considerably higher in newborns (typically with umbilical cord infections) and in the elderly without adequate immunization. Yet, until quite recently, most recommendations for tetanus toxoid mention re-immunizing every 10 years until age 65, with no provision for those of us who are older. Below that age, studies of armed forces personnel have shown adequate protection for up to twelve years.

Over the past few years the recommendations for immunization in older adults (age 65 and up) have gradually changed. In late 2010, although there was no formally FDA approved Tdap (Tetanus, diphtheria and pertussis (whooping cough), vaccine for those in that age range, the CDC's Advisory Committee on Immunization Practices (ACIP) suggested Tdap be given to all 65+ adults who were in close contact with infants and others in that older age range could get Tdap. By early 2012 ACIP approved the use of Tdap in all older adults, with one product (Boostrix) being preferred but the use of either of the two kinds of Tdap available in the United States being valid.

Wound management recommendations have similarly changed recently. If more than 5 years have elapsed since the last tetanus booster (which may have been Td), then anyone who is 19 and older should get Tdap.

The last time I got a dirty puncture wound I thoroughly cleaned it and hurried off to the hospital's Urgent Care Clinic, shot record in my hand.

When did you last have a tetanus booster shot?

When did you last have a tetanus booster shot?

Between tetanus bacilli, flesh-eating strep, drug-resistant staph and all their compatriots I've changed my approach to outdoor work. Although I do much less of it than in years past, I still not infrequently come home with a dirty scratch. I really scrub my hands and occasionally add a topical antibiotic ointment and a band-aid.

I think you should ask your physician when your last tetanus booster was given and see what they'd suggest for supposedly minor cuts and punctures.

You may prevent one or another of the serious bacterial complications most of us have heard about happening, even in our own communities.



Cholera: Part 1 background and history

Sunday, February 24th, 2013

An 1882 monument to victims of cholera

Cholera is an infectious illness, found only in humans, caused by a bacteria in contaminated water, leading to severe diarrhea and dehydration and capable of killing its victims in a matter of hours if untreated. When I read about the disease for the second time in decades (the first time was after a 21st-century epidemic in Haiti), I was amazed at how quickly a victim can lose 10% or more of their body weight in severe cases; e.g., eight quarts between my normal bedtime and when I usually wake up. Many people who ingest the bacteria don't develop any symptoms, but if they do and lack modern re-hydration therapy, their chance of dying is 40-60%.

In all likelihood it is an ancient disease with writings from the lifespan of Buddha  (563-583 BCE) and from the time of Hippocrates (460-377 BCE) revealing diseases that presumably were  cholera. It has, over the last several hundred years, been a major killer of mankind, causing millions of deaths in the 19th century.   Those numbers place it among the deadliest of infectious illnesses, in the company of smallpox, the Spanish flu, bubonic plague, AIDS and malaria.

A CBC News article online with the title "Cholera's Seven Pandemics," starts with a major outbreak in India near the Ganges River delta. Between 1817 and 1823 there were 10,000 deaths among the British soldiers stationed in that country, estimates of hundreds of thousands of fatal cases among native Indians and 100,000 dying in Java in the year 1820. The second pandemic began in 1829, again in India, and spread to Russia, Finland, Poland, England, Ireland, Canada, the U.S. and Latin America, before another outbreak in England and Wales that killed 52,000 over two years. The sixth pandemic killed more than 800,000 people in India alone and, over the next 24 years swept over parts of Europe, Russia, northern Africa and the Middle East.

The National Library of Medicine's website entry on cholera associates it with crowding, poor sanitation, famine and war. India has remained a source as the disease is endemic (ever present) there. People get cholera by eating or drinking either contaminated food or water; the medical term is the fecal-oral route.

In the summer of 1854 London was the epicenter of a deadly outbreak. Dr. John Snow, a famous British physician born March 15th, 1813, had been noted as a pioneer in anesthesiology, using chloroform to assist in Queen Victoria's delivery of her eighth child in 1853.

Then, as documented in the book, The Ghost Map by Steven Johnson, Snow turned his investigative talents and keen mind to cholera, becoming in the process the modern father of epidemiology.

London's population had grown immensely and its sewage system was antiquated. In addition to basements filled with excrement, cesspools and drainage into water sources were rampant. A major concept of disease causation was the miasma theory. The term means "bad air" and the assumption was illness was caused by the presence in the air of a miasma, a ill-smelling vapour containing suspended particles of decaying matter .

Snow, on the other hand, felt cholera was caused by something ingested, most likely by drinking water contaminated by waste products.

In a painstaking and extremely clever investigation, Snow had, in a prior cholera outbreak in 1849 which was responsible for a dozen deaths in flats in a slum area, shown that two separate  sets of milieu had markedly differing death rates. All environmental parameters were essentially identical in the two groups with one exception; where they obtained their water. The group who suffered a much higher rate of illness got theirs from a company whose river source was in the same area where many sewers emptied.

Vibrio cholerae, the cholera bacteria

Five years later a much larger cholera epidemic provided an opportunity to more closely examine the water sources of the victims. One particular pump, seemingly providing clear water, proved to be the culprit. The Broad Street pump's output was examined by a Snow's colleague, a skilled microscopist Dr. Arthur Hassall, and found to contain what Hassall believed to be decomposed organic matter with oval-shaped tiny life-forms felt to be feeding on that organic substance. Snow was not aware then of the 1854 work of an Italian scientist, Filippo Pacini, who had examined the intestines of patients dying from cholera in Florence and found a comma-shaped bacillus he termed a Vibrio.

The proponents of the miasma theory did not yield easily, but Snow's map of the location of deaths from cholera eventually let his hypothesis of a water-borne illness prevail.  Then an assistant curate (church figure in charge of a parish) named Henry Whitehead who had read Snow's papers on the epidemic eventually found the index (first) case, a baby Lewis. As a result, the Broad Street pump was excavated and a direct connection to a cesspool was found.

The juxtaposition of Snow's scientific data and Whitehead's work as a beloved neighborhood figure led to the local Vestry Committee's report endorsing the water-as-culprit theory.

The city subsequently launched a major project to carry waste and surface water away from Central London.





Five years later, he