Health Watch

March 24 was World TB Day:

TB need not be terminal

The world TB day which is held each year on March 24 is intended to promote awareness, knowledge and motivation for action against tuberculosis worldwide. Hundred and thirty one years ago, after the discovery of the Koch's bacillus, TB, even today remains an epidemic in much of the world despite the fact that effective cures have been made available for decades. This greatest killer of human beings in all history still at work despite many scientific breakthroughs.

Currently tuberculosis has become the deadliest infectious disease in the world and the number one infectious killer, causing 3 million deaths per year both amongst youth and adults. This has such serious implications to the world economy, because tuberculosis kills or disables mainly young people, who form the productive sector of the economy, so much so that the World Health Organization declared tuberculosis a global emergency in 1993.

Tuberculosis, appearing in forms resistant to multiple drugs (MDR TB) that cannot be cured by once effective medicines together with its deadly ally, the Human Immunodeficiency Virus (HIV) has emerged as one of the most potent threats to the existence of mankind and the biggest threat to the world economy.

Why cannot tuberculosis be eliminated? Very simply, it is due to the low priority that tuberculosis has been assigned by health policy- makers. In many low to middle income countries, less than 1% of the annual health budget is allocated for tuberculosis - unbelievable, but true. Why this silence? Is it because Tuberculosis is something to be swept under the carpet, covered up, and its existence ignored? The tragic consequence is because of inadequate funding, inefficient tuberculosis control programmes have actually led to a worsening of the world tuberculosis situation.

This is because the patients are not cured, but do not die of the disease either, leaving a pool of inadequately or improperly treated patients disseminating multi-drug resistant tuberculosis in the community. In other words, in a poor tuberculosis control programme many patients will die of the disease, true, but there will also be half treated half dead patients disseminating the disease to healthy people.

Also, if there were no tuberculosis drugs at all in a country, there would be no multi - drug resistant tuberculosis for it is improper use of anti- tuberculosis drugs that creates multi -drug resistant tuberculosis. In other words, multi drug resistant tuberculosis is entirely man made by doctors, sometimes the patients themselves or the drug companies. Doctors because they may prescribe drugs in the wrong dosage, wrong combination or the wrong number of drugs, due to ignorance. Patients, because they have not been told the correct dosage or combination or because, if the patient has to buy the drugs (as happens when the patient consults a physician privately), he /she may buy less than the prescribed amount of drugs or take lesser than the prescribed dose, to make the drugs last longer, or because he has no money to buy all the drugs for the prescribed period in addition to paying the consultant's fee. The drug companies, because they may produce poor quality drugs which may not have the correct quantity of the drugs in them.

Patient supervision

However, all is not gloomy. It has been shown conclusively in countries poorer than Sri Lanka, such as Nepal and Bangladesh (with per capita GNP of around US$200, compared to a per capita GNP of US$ 840 for Sri Lanka) that more than 90% of Tuberculosis patients can be cured and the emergence of multi drug resistant tuberculosis controlled if the treatment of tuberculosis patients is completely supervised. In other words, if someone (Nurse, Health, Volunteer worker, public health worker, a relative ) actually watches the patient swallowing the drugs.

Tuberculosis patients (or for that matter any patient) have the bad habit of forgetting to take their drugs when they feel better, or throwing their drugs away when they feel better. The very efficacy of modern anti tuberculosis drugs is in a way disadvantageous, because patients feel normal too soon, leading them to forget to take their medication or to take it irregularly. Directly supervised treatment circumvents this hurdle and has now been shown to be the only way rampant tuberculosis can be controlled.

As Tuberculosis has been declared as a global emergency many efforts are being made to find new effective solutions and strategies in service, design and delivery to eliminate this global menace which are appearing in various forms.

1. New tools, drugs and strategies which are being researched and tried out bringing effective results.

The DOTS strategy

Represents a major break through in controlling tuberculosis. No other TB control strategy comes close to being as effective and are affordable as DOTS.

The advantages to the community by using the DOTS strategy are numerous.

A). Cures the patient

No other TB control strategy has consistently demonstrated such high cure rates. DOTS produces cure rates as high as 95 percent, even in the poorest of countries. TB programmes not using DOTS often cure only 40 percent of their patients.

B). Prevents New Infections

DOTS stops the TB Bacillus at the source by curing the infectious patient.

A patient who is not cured will infect, on average, 10 to 15 other people every year.

C) Stops MDR TB

DOTS makes it virtually impossible to cause a patient to develop the incurable forms of TB that are becoming more common.

Other treatment strategies are actually causing multidrug - resistant TB, and may be doing more harm than good.

D) Cost Effective

A six month supply of medicines for DOTS cost only $ 11 per patient in some parts of the world. This can be less than the price of a few bottles of aspirin. The World Bank has ranked the DOTS strategy as one of the most cost effective of all health interventions.

E. Community Based

DOTS have been demonstrated to add as many years of life as currently available protease inhibitors to HIV positive people. Yet, the medicines used for DOTS are only one hundred percent of the cost.

F. Protects the workforce

Nearly 80 percent of those ill with TB are in their most economically productive years of life. These youthful TB patients represent a workforce nearly as large as the number of people employed by the world's 20 biggest international corporations.

G. Protects International Travelers

There is no other feasible way to protect the world's 500 million annual international travelers from TB. The only safeguard is to use DOTS more widely to reduce the number of infectious TB cases worldwide.

H. Stimulates Economies

The DOTS strategy offers relatively quick payoffs to the economies of developing countries. Studies in India and Thailand have shown that a small investment in the DOTS strategy can save their economies, billions of US dollars.

I. Proven Effective

DOTS has been successfully implemented in a wide variety of conditions, including Sri Lanka, India, Tanzania, Guinea, China, Bangladesh, New York City and Peru. Currently, nearly 70 countries have begun using DOTS and are achieving good results.

Stop TB Strategy

2. The implementation of the “Stop TB Strategy”

Has greatly expanded the Tuberculosis diagnosis and treatment services and has saved millions of lives. Development of new tools is a major component of the revised global efforts to stop TB. Progress has been made in this area. They are now in the evaluation process and will be incorporated in to the TB control programme in the near future. New and powerful drugs for the Chemotherapy of Tuberculosis are also been developed and progressively introduced in to the treatment regimen.

3. Systematic Strategy for screening and monitoring high risk zones where the population is concentrated such as,

a. Garment industries

b. Factories

c. Prison institutions

d. Rehabilitation camps

e. Elderly peoples institutions

f. Orphanages

g. Mental asylums

h. Low income communities residing in congested areas.

4. Changing of the campaign terminology strategy.

In the campaign terms such as TB suspects, defaulters, Control, Campaign tend to criminalize the patient and patient unfriendly. Therefore in the control of Tuberculosis, consideration is being given to use terms which are more humane and patient- friendly which will make the patient more co - operative.

5. Greater involvement of NGO's

Recruiting and mobilizing volunteers for treatment and supervision which will make Tuberculosis programmes efficient.

Compared to other South Asian Countries, Sri Lanka is far ahead in terms of quality of life, life expectancy, literacy maternal mortality. This is a constant source of amazement to developed countries, who wonder how we can maintain such indices comparable to a developed country. The answer is, of course the standard of literacy and education of the Population and the solid health infrastructure and active NGOs.

- This article was sent by The Ceylon National Association for the Prevention of Tuberculosis (CNAPT.)

Natural way to prevent osteoporosis

M.Piratheeban

Building healthy and strong bones in teenage and early adulthood of life is important to prevent osteoporosis and any other bone problems in later life. Osteoporosis occurs when the body fails to form enough new bone, when too much existing bone is reabsorbed by the body, or both. In osteoporosis condition bone becomes weak and more fragile, which means easily breakable even from a small fall.

In Sri Lanka among adults who are less than fifty years of age, nine percent of women and three percent of men have osteoporosis and among people above fifty years of age, 27 percent of women and seven percent of men have osteoporosis. Prevention of osteoporosis should be started at childhood. Maximum bone growth occurs at adolescence and peak bone mass occurs between the ages of 25 and 35 years. Bone continuously removes calcium and restores it again.

If bone removes more calcium than restoration, it may cause osteoporosis. Let's see it in a simple way. Consider bone as bank where you save calcium. You earn calcium (eat calcium rich foods), deposit it in bone and your body spends it when it needs. Whether you earn (eat calcium rich foods) and deposit the calcium or not, your body does not consider that and it spends calcium continuously.

Therefore if you fail to earn more calcium (eat calcium rich foods) and deposit it in bone, one day you will end up with low balance in your account (Osteoporosis). In this bank you can deposit calcium until 30-35 years of age only, after that withdrawal only can be done. If you deposit more calcium before 30-35 years old, you can spend throughout your later life without ending up with low account balance (Osteoporosis).

Let's see what you should do to deposit more calcium in your bone.

* Eat calcium and vitamin D rich foods.

* Eat five different vegetables and two to three fruits per day.

* Do at least 30 minutes of exercises most preferably all days of a week.

* Stop smoking and limit alcohol to no more than two to three drinks per day.

Eat calcium and vitamin D rich foods

Calcium is the major nutrient need for health bone. Ninety-nine per cent of calcium in our body is in our bone and teeth. Everyday calcium is lost from our body through feces, urine, sweat, skin, and hair. To compensate these lost, it is important to get enough calcium through diet.

Milk and milk products such as cheese, yogurt and curd are rich in calcium and easily absorbed by our body. Other than dairy products canned fish, small fishes, vegetables like cabbage, beans, spinach, broccoli, okra, pulses such as soybeans, fruits like orange, dried plums and cereals also contain a significant amount of calcium. By drinking two or three of cup of milk, you can gain daily required calcium for your body.

(See Table 1 for Calcium requirements for Sri Lankans. See table 2 for Calcium content of some foods.)

Vitamin D is other most important nutrient for healthy bones. Vitamin D is important for calcium absorption from our diet and calcium deposition in bones. If there is a deficiency of vitamin D in your body, it will make you lose bones even though you take in enough calcium. Therefore getting an adequate amount of vitamin D is most important. You can get vitamin D by two ways. They are

* Diet

* Sunlight

Fishes like sardine, herrings, fish liver oil and other animal foods are good sources of vitamin D. Egg, beef and milk also contain some amount of vitamin D. Nowadays vitamin D is purposefully added by the food manufacturers to increase the nutritional value of food products such as milk powder, flavored milk packets and breakfast cereals. Read the label and search for the words “fortified with vitamin D” or “enriched with vitamin D” before you choose the food. Adequate exposure to the sunlight also helps to fulfill our vitamin D need. Our skin has ability to produce vitamin D from cholesterol. Five to twenty minutes exposure to sunlight is enough to produce vitamin D required by our body. Lighter skin needs less time and dark skin needs little more time to synthesis required vitamin D. Mid-day is the best time of a day to synthesis vitamin D, less time is needed to synthesis required vitamin D compared to other times of a day.

Direct sunlight exposure is needed for vitamin D synthesis because UV-B radiation that is responsible for vitamin D synthesis cannot penetrate glasses.

Vegetables and fruits

Eat five different vegetables and two to three fruits per day. Eat at least five different vegetables and two to three fruits per day. Fruits and vegetables are rich in vitamins and minerals which are important for the born health such as vitamins like vitamin K, Vitamin C, and vitamin A, and minerals like magnesium, potassium, fluoride and phosphorus.

Exercises

Do at least 30 minutes of exercises most preferably all days of a week Doing at least 30 minutes of exercises most preferably all days of a week not only helps you keep away from diseases like diabetes, high blood pressure and heart diseases, but also helps you build strong and healthy bones. Especially weight-bearing exercises play most important role in building strong bone.

Some examples for weight-bearing exercises are jogging, hiking, running and stair climbing. Doing regular weight bearing exercises when you are young (at least three days per week in your exercise plan) can help to reach the peak bone mass and keep the bone healthy and strong throughout your life time.

Sports like tennis, foot ball, volley ball and basket ball also help to build strong bons. Muscle-strengthening exercises like lifting weights, using elastic exercise bands, using weight machines and lifting your own body weight can also help build strong and healthy bone.

Although swimming is not a weight-bearing exercise, it also helps to build strong bones But these exercises are not recommended to the people who are already affected by osteoporosis and have risk of osteoporosis, because these exercises may cause bone breakage due to the weakness of bone.

People who have osteoporosis and risk of osteoporosis or people who are not sure about their bone health should consult a physician before they start exercising.

Stop smoking

Stop smoking and limit alcohol to no more than two to three drinks per day. Several researchers have found that smoking shows a negative impact on bone health. Smoking causes weak bones. Drinking too much of alcohol can also cause bone loss. If you are an alcoholic, limit yourself to no more than 2 to 3 drinks a day. Ultimately, eating calcium rich foods like milk and milk products two to three per day, 5 to 20 minutes of exposure to sunlight, eating five different vegetables and two to three fruits per day, engaging in at least 30 minutes of exercises most preferably all day of a week and non smoking and limiting alcohol no more than two to three drinks per day will definitely improve your bone health and help you stay away from osteoporosis.

Even if you are little older don't think you are late, whatever your age, if you start to practise these habits at least now, you can improve your bone health for the rest of your life.

(The writer is a third year student of the Department of Applied Nutrition, Faculty of Livestock, Fisheries and Nutrition, Wayamba University of Sri Lanka.)