Dengue Fever

What is Dengue fever?

Dengue fever (pronounced Den-gay) is a viral infection caused by the female mosquito (Aedes aegypti and Aedes
albopictus). Dengue fever occurs in tropical and sub-tropical regions and usually increases in the hot and humid months.
Dengue fever is not a new disease. It was discovered several hundred years ago. In recent years, dengue fever has
become a major international public health concern.

Dengue fever nicknamed "breakbone fever" because dengue patients usually express contorted movements due to
intense joint and muscle pain. Benjamin Rush from Philadelphia, US, first described "breakbone fever" in 1780. Slaves
who developed dengue fever in the West Indies were said to have "dandy fever" because of their posture and gait.

Dengue fever lasts for approximately 7 days, despite its sudden and acute onset. However, extra precautions should be
taken after the recovery period. These precautions will help prevent severe illness from occurring in some people, such
as dengue haemorrhagic fever (DHF) or dengue shock syndrome (DSS). These illnesses are potentially lethal and are
today the leading cause of childhood mortality in several Asian countries.

There are two types of dengue fever:

• Dengue fever which manifests itself as a flu-like illness.

• Dengue hemorrhagic fever which is a severe, often fatal, complication of dengue fever.

Dengue Outbreak

Aside from the Philippines, dengue problem is also being experienced in countries that have tropical climate like in
neighboring Asian countries such as Malaysia, Indonesia, Laos, India, Taiwan;

Dengue is also found in South American countries such as Brazil, Puerto Rico, El Salvador, Guatemala, Mexico and the
continent country Australia.

Even Singapore which is known for its clean surroundings have not been spared of an outbreak.

How is Dengue fever transmitted?

Dengue viruses are transmitted to humans (host) through the bites of the female striped Aedes aegypti mosquito
(vector). This variety of mosquito breeds easily during the rainy seasons but can flourish in peridomestic fresh water, e.g.
water that is stored in plastic bags, cans, flowerpots and old tires. The dengue virus is transmitted to its host during
probing and blood feeding. The mosquito may carry the virus from one host to another host and the mosquito is most
active in the early morning and later afternoon. A mosquito bite can cause the disease. Incubation period occurs when
the viruses has been transmitted to the human host. The period ranges from 3 to 15 days (usually lasting for 5-8 days)
before the characteristics of dengue appear. During incubation time, the dengue viruses multiply.

What are the characteristics of Dengue fever?

The Dengue virus travels to various glands in the body where it multiples. It then travels to the bloodstream, affecting
some changes to these blood vessels. The virus may cause the blood vessels to swell and leak. The spleen and lymph
nodes may also become swollen. Patches of liver tissue may die. Furthermore, a process known as disseminated
intravascular coagulation (DIC) occurs. During this process, chemicals used to clot blood are used up, and thus severe
bleeding (hemorrhage) occurs internally as well as the skin.

The signs and symptoms of Dengue fever are as follows:

- High fever (104 F, 40°C) - Headache - Enlarged lymph nodes

- Chills - Red eyes, pain in the eyes - Deep muscle and joint pains
(during first hours of illness)
- Loss of appetite - Headache - Nausea and vomiting

- Nausea and vomiting - Red eyes, pain in the eyes - Low blood pressure and heart
rate
- Low blood pressure and heart - Enlarged lymph nodes
rate - Extreme fatigue
- Deep muscle and joint pains
- Extreme fatigue- High fever (104 (during first hours of illness)
F, 40°C)
- Loss of appetite
- Chills
Basically, dengue commences with high fever and other signs as listed above for 2 to 4 days. Then, the temperature
drops rapidly and intense sweating takes place. After about a day with normal temperature and a feeling of well-being,
the temperature rises abruptly again. Rashes (small red bumps) show up on the arms, legs and the entire body
simultaneously along with fever. However, rashes rarely occur on the face. The palms of the hands and soles of the feet
may be swollen and bright red. Although the patient may feel exhausted for several weeks, most cases of dengue take
approximately one week to recover. Once a person recovers from dengue, he or she will have antibodies in their
bloodstream which will prevent them from having a relapse for about a year.

Treatment

There is no specific treatment to shorten the course of dengue fever. Medications are given to alleviate the signs and
symptoms. Aspirin should not be given to patients. It will cause severe bleeding. Hence, it is advisable to take
paracetamol to relieve muscle and joint aches, fever and headache. The patient may be required to be sponged down
with water at room temperature using a wet, squeezed out towel for about 20 minutes at a time. This will help to help
lower the high temperature. Ice water should not be used for this purpose. However, bed rest is essential to a speedy
recovery and the patient should consume plenty of water which will help to alleviate the illness. Patients should be kept
in a room that has screens to prevent mosquitoes from entering or else under mosquito netting until the second period
of fever has subsided. Hence, mosquitoes cannot bite them. If the patient is bitten then the dengue virus may be
transmitted to the mosquito and then to another host.

Immunization

There is no vaccine to protect against dengue. Developing a vaccine against dengue/severe dengue has been challenging
although there has been recent progress in vaccine development. WHO provides technical advice and guidance to
countries and private partners to support vaccine research and evaluation. Several candidate vaccines are in various
phases of trials.

What is Dengue Hemorrhagic Fever (DHF)?

Dengue hemorrhagic fever occurs when the dengue virus re-infects a person who previously has experienced dengue
fever. In this case, the previous infection teaches the immune system to recognize the virus, resulting in the immune
system over reacting. DHF is also known as dengue shock syndrome (DSS) and the symptoms in this case are severe. It is
a potential fatal immunological reaction and tends to affect children under 15 years old.

The signs and symptoms of DHF are as follows:

- Abdominal pain - Sore throat and cough

- Hemorrhage (severe bleeding) - Pneumonia

- Circulatory collapse (shock) - Inflammation of the heart

- Nausea and vomiting - Blood in the stool

- Bleeding of the nose and gums - High fever (40 -41 C)

The initial symptoms of DHF are high fever and severe headache. Small purplish spots (petechiae) can be seen on the
skin. This is because blood is leaking out of the vessels. Large bruised areas appear due to severe bleeding. Sometimes,
patients may begin to vomit a substance that appears as coffee grounds. This is actually a sign of bleeding in the
stomach. The severe hemorrhage results in a decrease of blood in the body. The low blood flow will unable to maintain
adequate supply of blood to meet the metabolic requests of the cells in the body. This state of low blood flow is the
defined as Dengue shock syndrome (DSS).

Patients with DHF must be closely monitored for the first few days until their condition is stabilized. The patient's
condition may suddenly worsen after few days if the fever has not subsided. The temperature will then suddenly drop
and the patient shows signs of circulatory failure. The patient may rapidly go into a critical state of shock (DSS) and die
within 12 to 24 hours. However, he or she may recover quickly after appropriate volume replacement therapy. Fluids are
infused to patients to avoid dehydration. Sometimes, blood transfusions may be necessary if severe bleeding occurs. In
addition, oxygen is given to cyanotic (bluish) patients.

Prevention and Control

At present, the only method of preventing and controlling dengue fever is to eradicate the mosquito population. They
are a number of ways to combat the vector mosquitoes:

- Improved water storage practices. Cover all containers to prevent egg laying female mosquitoes access to it.

- Implement proper solid waste disposal.

- Eliminate any sources that may collect water such as tins, bottles, plastic food containers and old tires. Mosquitoes
breed easily in any source of standing water.

- Appropriate insecticides, such as larvicide's can be added to water containers and man-made ponds. The insecticides
can prevent mosquitoes breeding for several weeks. However, they must be re-applied as per directions.

- Always clean and check drains to ensure they are not blocked especially during the rainy season.

- Breed small mosquito-eating fishes in an artificial pond to eradicate the mosquito larvae.

In addition to the above, there are a number of factors to help prevent the mosquito being attracted to human prey.

- Avoid wearing dark and tight clothing because mosquitoes are attracted to dark colours. Wear loose, white and long
clothes, which cover the whole body. Mosquitoes find it difficult to bite through loose clothes than tight fitting clothes.

- Environmental conditions. It is suggested to sleep under mosquito netting or in a room which has mosquito screens on
the windows. Mosquitoes are unlikely to bite in an air-conditioned room and under strong fans. Mosquito coils are also
useful to help prevent mosquitoes from entering the room.

- Apply mosquito repellants.

- Avoid reduce outdoor activities during morning and late afternoon because Aedes mosquitoes are daytime feeders.

#THE USE OF FOGGING MEASURES

Fogging, using the nauseous gas Malathion, is used to kill the Aedes aegypti mosquito, the carrier of the dengue virus, to
stop transmission of the disease.

• The chemical contains toxins that may cause intestinal problems, brain damage, respiratory problems, among others.

• Fogging does not totally eradicate the dengue-carrying mosquito as it just transfers to other place which had not been
fogged

• Fogging just kills the adult mosquito but leaves the kiti-kiti (larvae) to thrive
• Fogging is only advisable in highly-concentrated areas where there are already outbreaks in the dengue case. To
declare an outbreak, there must be clustering of cases in significant areas.

HOW TO FIGHT THE DENGUE VIRUS

The best way to fight dengue fever is prevention and the way to do this is to arm yourself with information regarding
this disease.

Knowing how to protect one's self from mosquito bites will keep you and your family from getting sick.

More effective dengue prevention and controlling programs are needed, rather than using the fogging method which is
highly risky to health and environment.

There are four strategies to fight dengue:

1) search and destroy mosquito breeding sites 3) seeking early treatment

2) the use of self protection measures 4) no indiscriminate fogging

like using mosquito nets

WHO response

WHO responds to dengue in the following ways:

•supports countries in the confirmation of outbreaks •develops new tools, including insecticide products and
through its collaborating network of laboratories; application technologies;

•provides technical support and guidance to countries •gathers official records of dengue and severe dengue
for the effective management of dengue outbreaks; from over 100 Member States;

•provides training on clinical management, diagnosis •publishes guidelines and handbooks for case
and vector control at the regional level with some of its management, dengue prevention and control for
collaborating centres; Member States.

•formulates evidence-based strategies and policies;

Warning signs of Dengue Shock Syndrome are

 Severe abdominal pain,  Change in temperature,

 Vomiting,  Mental irritability.
#Note:

Jawatan orang y buat fogging=PKA(pembantu kesihatan awam)

Dengue mosquitoes do not breed in swamps or drains. They tend to breed in containers of stagnant water inside and
outside the home.

Aedes aegypti mosquitoes generally known as a container breeder normally breed in pure water which is not very deep.
Sometimes it could breed even in slightly polluted or slightly brackish water.

Abandoned water tank

Mosquitos breeding in a quart jar ..

The common breeding places of the Aedes mosquito are so varied and so many:

We normally speak about discarded plastic cups, coconut shells, empty bottles, containers used as ant traps in houses,
tree holes, drums and containers used for collection and store water.
They also breed in cans, buckets, jars, blocked roof gutters and tarps, sheaths of some plants like bromeliad and bananas
etc.

Other productive containers for dengue are discarded tyres, toilet tanks, flower vases and pots.

If you remove these sources, your risk of being bitten by a Dengue mosquito is significantly reduced.

Water collected under the flower pot.

All households are also urged to constantly check any collection of water in their dish drains and water dispensers
because in inspections, many dengue-carrier mosquitoes lay their eggs in these containers.

A research study conducted by the International Health for Tropical Medicine showed that productive containers for
dengue breeding sites are mostly found indoors.

Tyres kept outdoors collect rain water ..

Many breeding places of the mosquitoes are found right inside of houses and yards.

In some places families who cannot afford water pumps often end up storing water in large water receptacles like jugs,
cans, drums and plastic jars.

These stored water become stockpile of most families for several days becoming good breeding places of mosquitoes.

Flower pot with water collection ..

Huge water storing containers without tight fitting lids

that cannot be emptied easily..

There are also so many unsuspected places in our garden where water remains for more than 7 days and these could be
Aedes mosquito breeding place.

Always throw away stagnant water that collects in every possible container that you can find in your surroundings.
 Malaria

Overview

Malaria is a mosquito-borne infectious disease of humans and other animals caused byprotists (a type of
microorganism) of the genus Plasmodium. It begins with a bite from an infected female Anopheles mosquito, which
introduces the protists through saliva into thecirculatory system. In the blood, the protists travel to the liver to mature
and reproduce. Malaria causes symptoms that typically include fever and headache, which in severe cases can progress
to coma or death. The disease is widespread in tropical andsubtropical regions in a broad band around the equator,
including much of Sub-Saharan Africa, Asia, and the Americas.

Five species of Plasmodium can infect and be transmitted by humans. The vast majority of deaths are caused by P.
falciparum and P. vivax, while P. ovale, and P. malariae cause a generally milder form of malaria that is rarely fatal. The
zoonotic species P. knowlesi, prevalent in Southeast Asia, causes malaria in macaques but can also cause severe
infections in humans. Malaria is prevalent in tropical and subtropical regions because rainfall, warm temperatures, and
stagnant waters provide habitats ideal for mosquito larvae. Disease transmission can be reduced by preventing
mosquito bites by distribution ofmosquito nets and insect repellents, or with mosquito-control measures such as
sprayinginsecticides and draining standing water.

Malaria is typically diagnosed by the microscopic examination of blood using blood films, or with antigen-based rapid
diagnostic tests. Modern techniques that use the polymerase chain reaction to detect the parasite's DNA have also been
developed, but these are not widely used in malaria-endemic areas due to their cost and complexity. The World Health
Organization has estimated that in 2010, there were 219 million documented cases of malaria. That year, between
660,000 and 1.2 million people died from the disease (roughly 2000–3000 per day),[1] many of whom were children in
Africa. The actual number of deaths is not known with certainty, as accurate data is unavailable in many rural areas, and
many cases are undocumented. Malaria is commonly associated with poverty and may also be a major hindrance to
economic development.

Despite a need, no effective vaccine currently exists, although efforts to develop one are ongoing. Several medications
are available to prevent malaria in travellers to malaria-endemic countries (prophylaxis). A variety ofantimalarial
medications are available. Severe malaria is treated with intravenous or intramuscular quinine or, since the mid-2000s,
theartemisinin derivative artesunate, which is superior to quinine in both children and adults and is given in combination
with a second anti-malarial such as mefloquine. Resistance has developed to several antimalarial drugs; for example,
chloroquine-resistant P. falciparumhas spread to most malarial areas, and emerging resistance to artemisinin has
become a problem in some parts of Southeast Asia.

Signs and symptoms

The signs and symptoms of malaria typically begin 8–25 days following infection;however, symptoms may occur later in
those who have taken antimalarial medications as prevention.Initial manifestations of the disease—common to all
malaria species—are similar to flu-like symptoms, and can resemble other conditions such assepticemia, gastroenteritis,
and viral diseases.The presentation may includeheadache, fever, shivering, arthralgia (joint pain), vomiting, hemolytic
anemia, jaundice,hemoglobinuria, retinal damage, and convulsions. Approximately 30% of people however will no
longer have a fever upon presenting to a health care facility. Owing to the non-specific nature of disease presentation,
diagnosis of malaria in non-endemic countries requires a high degree of suspicion, which might be elicited by any of the
following: recent travel history, splenomegaly (enlarged spleen), fever without localizing signs, thrombocytopenia, and
hyperbilirubinemia combined with a normal peripheralblood leukocyte count.

The classic symptom of malaria is paroxysm—a cyclical occurrence of sudden coldness followed by rigor and then fever
and sweating, occurring every two days (tertian fever) in P. vivax and P. ovale infections, and every three days (quartan
fever) forP. malariae. P. falciparum infection can cause recurrent fever every 36–48 hours or a less pronounced and
almost continuous fever.

Severe malaria is usually caused by P. falciparum (often referred to as falciparum malaria). Symptoms of falciparium
malaria arise 9–30 days after infection. Individuals with cerebral malaria frequently exhibit neurological symptoms,
including abnormal posturing,nystagmus, conjugate gaze palsy (failure of the eyes to turn together in the same
direction), opisthotonus, seizures, or coma.

Complications

There are several serious complications of malaria. Among these is the development of respiratory distress, which
occurs in up to 25% of adults and 40% of children with severe P. falciparum malaria. Possible causes include respiratory
compensation of metabolic acidosis, noncardiogenic pulmonary oedema, concomitant pneumonia, and severe anaemia.
Acute respiratory distress syndrome (ARDS) may develop in 5–25% in adults and up to 29% of pregnant women but it is
rare in young children. Coinfection of HIV with malaria increases mortality. Renal failure is a feature of blackwater fever,
where hemoglobin from lysed red blood cells leaks into the urine.

Infection with P. falciparum may result in cerebral malaria, a form of severe malaria that involves encephalopathy. It is
associated with retinal whitening, which may be a useful clinical sign in distinguishing malaria from other causes of
fever. Splenomegaly, severe headache, hepatomegaly (enlarged liver), hypoglycemia, and hemoglobinuria with renal
failure may occur.

Malaria in pregnant women is an important cause of stillbirths, infant mortality and low birth weight,particularly in P.
falciparuminfection, but also with P. vivax.

Cause

Malaria parasites belong to the genus Plasmodium (phylum Apicomplexa). In humans, malaria is caused by P.
falciparum, P. malariae,P. ovale, P. vivax and P. knowlesi.Among those infected, P. falciparum is the most common
species identified (~75%) followed by P. vivax (~20%). Although P. falciparum traditionally accounts for the majority of
deaths,recent evidence suggests thatP. vivax malaria is associated with potentially life-threatening conditions about as
often as with a diagnosis of P. falciparuminfection.P. vivax proportionally is more common outside of Africa.There have
been documented human infections with several species of Plasmodium from higher apes; however, with the exception
of P. knowlesi—a zoonotic species that causes malaria inmacaques—these are mostly of limited public health
importance.

Life cycle

The life cycle of malaria parasites: A mosquito causes infection by taking a blood meal. First, sporozoites enter the
bloodstream, and migrate to the liver. They infect liver cells, where they multiply into merozoites, rupture the liver cells,
and return to the bloodstream. Then, the merozoites infect red blood cells, where they develop into ring forms,
trophozoites and schizonts that in turn produce further merozoites. Sexual forms are also produced, which, if taken up
by a mosquito, will infect the insect and continue the life cycle.
In the life cycle of Plasmodium, a female Anopheles mosquito (the definitive host) transmits a motile infective form
(called the sporozoite) to a vertebrate host such as a human (the secondary host), thus acting as a transmission vector. A
sporozoite travels through the blood vessels to liver cells (hepatocytes), where it reproduces asexually
(tissueschizogony), producing thousands of merozoites. These infect new red blood cells and initiate a series of asexual
multiplication cycles (blood schizogony) that produce 8 to 24 new infective merozoites, at which point the cells burst
and the infective cycle begins anew.Other merozoites develop into immature gametes, or gametocytes. When a
fertilised mosquito bites an infected person, gametocytes are taken up with the blood and mature in the mosquito gut.
The male and female gametocytes fuse and form zygotes (ookinetes), which develop into new sporozoites. The
sporozoites migrate to the insect's salivary glands, ready to infect a new vertebrate host. The sporozoites are injected
into the skin, alongside saliva, when the mosquito takes a subsequent blood meal.

Only female mosquitoes feed on blood; male mosquitoes feed on plant nectar, and thus do not transmit the disease.
The females of theAnopheles genus of mosquito prefer to feed at night. They usually start searching for a meal at dusk,
and will continue throughout the night until taking a meal.Malaria parasites can also be transmitted by blood
transfusions, although this is rare.

Recurrent malaria

Symptoms of malaria can reappear (recur) after varying symptom-free periods. Depending upon the cause, recurrence
can be classified as either recrudescence, relapse, or reinfection. Recrudescence is when symptoms return after a
symptom-free period. It is caused by parasites surviving in the blood as a result of inadequate or ineffective treatment.
Relapse is when symptoms reappear after the parasites have been eliminated from blood but persist as dormant
hypnozoites in liver cells. Relapse commonly occurs between 8–24 weeks and is commonly seen with P. vivax and P.
ovale infections. P. vivax malaria cases in temperate areas often involveoverwintering by hypnozoites, with relapses
beginning the year after the mosquito bite. Reinfection means the parasite that caused the past infection was
eliminated from the body but a new parasite was introduced. Reinfection cannot readily be distinguished from
recrudescence, although recurrence of infection within two weeks of treatment for the initial infection is typically
attributed to treatment failure.

Pathogenesis

Malaria infection develops via two phases: one that involves the liver (exoerythrocytic phase), and one that involves red
blood cells, or erythrocytes (erythrocytic phase). When an infected mosquito pierces a person's skin to take a blood
meal, sporozoites in the mosquito's saliva enter the bloodstream and migrate to the liver where they infect hepatocytes,
multiplying asexually and asymptomatically for a period of 8–30 days.

After a potential dormant period in the liver, these organisms differentiate to yield thousands of merozoites, which,
following rupture of their host cells, escape into the blood and infect red blood cells to begin the erythrocytic stage of
the life cycle.The parasite escapes from the liver undetected by wrapping itself in the cell membrane of the infected host
liver cell.

Within the red blood cells, the parasites multiply further, again asexually, periodically breaking out of their host cells to
invade fresh red blood cells. Several such amplification cycles occur. Thus, classical descriptions of waves of fever arise
from simultaneous waves of merozoites escaping and infecting red blood cells.

Some P. vivax sporozoites do not immediately develop into exoerythrocytic-phase merozoites, but instead produce
hypnozoites that remain dormant for periods ranging from several months (7–10 months is typical) to several years.
After a period of dormancy, they reactivate and produce merozoites. Hypnozoites are responsible for long incubation
and late relapses in P. vivax infections, although their existence in P. ovale is uncertain.

Micrograph of a placenta from a stillbirthdue to maternal malaria. H&E stain. Red blood cells are anuclear; blue/black
staining in bright red structures (red blood cells) indicate foreign nuclei from the parasites

The parasite is relatively protected from attack by the body's immune system because for most of its human life cycle it
resides within the liver and blood cells and is relatively invisible to immune surveillance. However, circulating infected
blood cells are destroyed in thespleen. To avoid this fate, the P. falciparum parasite displays adhesive proteins on the
surface of the infected blood cells, causing the blood cells to stick to the walls of small blood vessels, thereby
sequestering the parasite from passage through the general circulation and the spleen.The blockage of the
microvasculature causes symptoms such as in placental malaria.Sequestered red blood cells can breach the blood–brain
barrierand cause cerebral malaria.

Although the red blood cell surface adhesive proteins (called PfEMP1, for P. falciparumerythrocyte membrane protein
are exposed to the immune system, they do not serve as good immune targets because of their extreme diversity; there
are at least 60 variations of the protein within a single parasite and even more variants within whole parasite
populations. The parasite switches through a broad repertoire of PfEMP1 surface proteins, thereby avoiding detection
by protective antibodies.

Genetic resistance

Due to the high levels of mortality and morbidity caused by malaria—especially the P. falciparum species—it has placed
the greatestselective pressure on the human genome in recent history. Several genetic factors provide some resistance
to it including sickle cell trait, thalassaemia traits, glucose-6-phosphate dehydrogenase deficiency, and the absence of
Duffy antigens on red blood cells.

The impact of sickle cell trait on malaria immunity is of particular interest. Sickle cell trait causes a defect in the
hemoglobin molecule in the blood. Instead of retaining the biconcave shape of a normal red blood cell, the modified
hemoglobin S molecule causes the cell to sickle or distort into a curved shape. Due to the sickle shape, the molecule is
not as effective in taking or releasing oxygen. Infection causes red cells to sickle more, and so they are removed from
circulation sooner. This reduces the frequency with which malaria parasites complete their life cycle in the cell.
Individuals who are homozygous (with two copies of the abnormal hemoglobin beta allele) have sickle-cell anaemia,
while those who are heterozygous (with one abnormal allele and one normal allele) experience resistance to malaria.
Although the shorter life expectancy for those with the homozygous condition seems to be unfavourable to the trait's
survival, the trait is preserved because of the benefits provided by the heterozygous form.

Malarial hepatopathy

Liver dysfunction as a result of malaria is rare and is usually a result of a coexisting liver condition such as viral hepatitis
or chronic liver disease. The syndrome is sometimes called malarial hepatitis, although inflammation of the liver
(hepatitis) does not actually occur. While traditionally considered a rare occurrence, malarial hepatopathy has seen an
increase, particularly in Southeast Asia and India. Liver compromise in people with malaria correlates with a greater
likelihood of complications and death.

Diagnosis

Malaria is usually diagnosed by the microscopic examination of blood films (gold standard )or by antigen-based rapid
diagnostic tests (RDT). Microscopy is the most commonly used method to detect the malarial parasite—about 165
million blood films were examined for malaria in 2010.Despite its widespread usage, diagnosis by microscopy suffers
from two main drawbacks: many settings (especially rural) are not equipped to perform the test, and the accuracy of the
results depends on both the skill of the person examining the blood film and the levels of the parasite in the blood. The
sensitivity of blood films ranges from 75–90% in optimum conditions, to as low as 50%. Commercially available RDTs are
often more accurate than blood films at predicting the presence of malaria parasites, but they are widely variable in
diagnostic sensitivity and specificity depending on manufacturer, and are unable to tell how many parasites are present.

In regions where laboratory tests are readily available, malaria should be suspected, and tested for, in any unwell
patient who has been in an area where malaria is endemic. In areas that cannot afford laboratory diagnostic tests, it has
become routine to use only a history of subjective fever as the indication to treat for malaria—a presumptive approach
exemplified by the common teaching "fever equals malaria unless proven otherwise". The drawback of this practice,
however, is overdiagnosis of malaria and mismanagement of non-malarial fever, which wastes limited resources, erodes
confidence in the health care system, and contributes to drug resistance.[39]Although polymerase chain reaction-based
tests have been developed, these are not widely implemented in malaria-endemic regions as of 2012, due to their
complexity.
Classification

Malaria is classified into either "severe" or "uncomplicated" by the World Health Organization (WHO).[3] Malaria is
diagnosed as severe when any of the following criteria are present, otherwise it is considered uncomplicated.[40]

• Decreased consciousness • Bleeding problems, or hemoglobin less than 5

g/dL
• Significant weakness such that the person is
unable to walk • Pulmonary edema

• Inability to feed • Blood glucose less than 2.2 mmol/L (or 40

mg/dL)
• Two or more convulsions
• Acidosis or lactate levels of greater than 5
• Low blood pressure (less than 70 mmHg in mmol/L
adults or 50 mmHg in children)
• A parasite level in the blood of greater than
• Breathing problems 100,000 per microlitre (µL) in low-intensity transmission
areas, or 250,000 per µL in high-intensity transmission
• Circulatory shock
areas
• Kidney failure or hemoglobin in the urine
According to the WHO, cerebral malaria is defined as a severe P. falciparum-malaria presenting neurological symptoms,
including coma (with a Glasgow coma scale rating of greater than 11, or a Blantyre coma scale greater than 3), or with a
coma that lasts longer than 30 minutes after a seizure.

Prevention

#An Anopheles stephensi mosquito shortly after obtaining blood from a human (the droplet of blood is expelled as a
surplus). This mosquito is a vector of malaria, and mosquito control is an effective way of reducing its incidence.

Methods used to prevent malaria include medications, mosquito elimination and the prevention of bites. The presence
of malaria in an area requires a combination of high human population density, high mosquito population density and
high rates of transmission from humans to mosquitoes and from mosquitoes to humans. If any of these is lowered
sufficiently, the parasite will eventually disappear from that area, as happened in North America, Europe and much of
the Middle East. However, unless the parasite is eliminated from the whole world, it could become re-established if
conditions revert to a combination that favours the parasite's reproduction.

Many researchers argue that prevention of malaria may be more cost-effective than treatment of the disease in the long
run, but the capital costs required are out of reach of many of the world's poorest people. There is a wide disparity in
the costs of control (i.e. maintenance of low endemicity) and elimination programs between countries. For example, in
China—whose government in 2010 announced a strategy to pursue malaria elimination in the Chinese provinces—the
required investment is a small proportion of public expenditure on health. In contrast, a similar program in Tanzania
would cost an estimated one-fifth of the public health budget.

Vector control

Walls where indoor residual spraying of

DDT(dichlorodiphenyltrichloroethane is an
organochlorine insecticide which is a colorless,
crystalline solid, tasteless and almost odorless chemical
compound) has been applied. The mosquitoes remain
on the wall until they fall down dead on the floor.
Vector control refers to preventative methods used to decrease malaria and morbidity and mortality by reducing the
levels of transmission. For individual protection, the most effective chemical insect repellents to reduce human-
mosquito contact are those based on DEET andpicaridin. Insecticide-treated mosquito nets (ITNs) and indoor residual
spraying (IRS) have been shown to be highly effective vector control interventions in preventing malaria morbidity and
mortality among children in malaria-endemic settings. IRS is the practice of spraying insecticides on the interior walls of
homes in malaria-affected areas. After feeding, many mosquito species rest on a nearby surface while digesting the
bloodmeal, so if the walls of dwellings have been coated with insecticides, the resting mosquitoes can be killed before
they can bite another victim and transfer the malaria parasite. As of 2006, the World Health Organization advises the
use of 12 insecticides in IRS operations, includingDDT and the pyrethroids cyfluthrin and deltamethrin). This public
health use of small amounts of DDT is permitted under the Stockholm Convention on Persistent Organic Pollutants
(POPs), which prohibits the agricultural use of DDT.[49]

One problem with all forms of IRS is insecticide resistance via evolution. Mosquitoes that are affected by IRS tend to rest
and live indoors, and due to the irritation caused by spraying, their descendants tend to rest and live outdoors, meaning
that they are not as affected—if affected at all—by the IRS, which greatly reduces its effectiveness as a defense
mechanism.

Mosquito nets help keep mosquitoes away from people and significantly reduce infection rates and transmission of
malaria. The nets are not a perfect barrier and they are often treated with an insecticide designed to kill the mosquito
before it has time to search for a way past the net. Insecticide-treated nets are estimated to be twice as effective as
untreated nets and offer greater than 70% protection compared with no net.Between 2000 and 2008, the use of ITNs
saved the lives of an estimated 250,000 infants in Sub-Saharan Africa.Although ITNs prevent malaria, only about 13% of
households in Sub-Saharan countries own them. A recommended practice for usage is to hang a large "bed net" above
the center of a bed to drape over it completely with the edges tucked in. Pyrethroid-treated nets and long-lasting
insecticide-treated nets offer the best personal protection, and are most effective when used from dusk to dawn.

Other methods

Community participation and health education strategies promoting awareness of malaria and the importance of control
measures have been successfully used to reduce the incidence of malaria in some areas of the developing
world.Recognizing the disease in the early stages can stop the disease from becoming fatal. Education can also inform
people to cover over areas of stagnant, still water, such as water tanks that are ideal breeding grounds for the parasite
and mosquito, thus cutting down the risk of the transmission between people. This is generally used in urban areas
where there are large centers of population in a confined space and transmission would be most likely in these areas.
Intermittent preventive therapy is another intervention that has been used successfully to control malaria in pregnant
women and infants, and in preschool children where transmission is seasonal.

Medications

Several drugs, most of which are used for treatment of malaria, can be taken to prevent contracting the disease during
travel to endemic areas. Chloroquine may be used where the parasite is still sensitive.[59] However, due to resistance
one of three medications—mefloquine (Lariam), doxycycline (available generically), or the combination of atovaquone
and proguanil hydrochloride (Malarone)—is frequently needed. Doxycycline and the atovaquone and proguanil
combination are the best tolerated; mefloquine is associated with death, suicide, and higher rates of neurological and
psychiatric symptoms.

The prophylactic effect does not begin immediately upon starting the drugs, so people temporarily visiting malaria-
endemic areas usually begin taking the drugs one to two weeks before arriving and should continue taking them for four
weeks after leaving (with the exception of atovaquone proguanil that only needs to be started two days prior and
continued for seven days afterwards). Use of prophylactic drugs is seldom practical for full-time residents of malaria-
endemic areas, and their use is usually restricted to short-term visitors and travellers to malarial regions. This is due to
the cost of purchasing the drugs, negative adverse effects from long-term use, and because some effective anti-malarial
drugs are difficult to obtain outside of wealthy nations. The use of prophylactic drugs where malaria-bearing mosquitoes
are present may encourage the development of partial immunity.
Treatment

The treatment of malaria depends on the severity of the disease. Uncomplicated malaria may be treated with oral
medications. The most effective strategy for P. falciparum infection is the use of artemisinins in combination with other
antimalarials (known asartemisinin-combination therapy, or ACT), which reduces the ability of the parasite to develop
resistance to any single drug component. These additional antimalarials include amodiaquine, lumefantrine, mefloquine
or sulfadoxine/pyrimethamine.Another recommended combination is dihydroartemisinin and piperaquine. ACT is about
90% effective when used to treat uncomplicated malaria. To treat malaria during pregnancy, the WHO recommends the
use of quinine plus clindamycin early in the pregnancy (1st trimester), and ACT in later stages (2nd and 3rd trimesters).
In the 2000s (decade), malaria with partial resistance to artemisins emerged in Southeast Asia.

Severe malaria requires the parenteral administration of antimalarial drugs. Until the mid-2000s the most used
treatment for severe malaria was quinine, but artesunate has been shown to be superior to quinine in both children and
adults. Treatment of severe malaria also involves supportive measures that are optimally performed in a critical care
unit, including management of high fevers (hyperpyrexia) and the subsequent seizures that may result from it, and
monitoring for respiratory depression, hypoglycemia, andhypokalemia. Infection with P. vivax, P. ovale or P. malariae is
usually treated on an outpatient basis (while a person is at home). Treatment of P. vivax requires both treatment of
blood stages (with chloroquine or ACT) as well as clearance of liver forms withprimaquine.

Prognosis

When properly treated, people with malaria can usually expect a complete recovery. However, severe malaria can
progress extremely rapidly and cause death within hours or days. In the most severe cases of the disease, fatality rates
can reach 20%, even with intensive care and treatment. Over the longer term, developmental impairments have been
documented in children who have suffered episodes of severe malaria. Chronic infection without severe disease can
occur, a form of acquired immunity where the immune system is also less responsive to Salmonella and the Epstein–Barr
virus.

Malaria causes widespread anemia during a period of rapid brain development, and also direct brain damage. This
neurologic damage results from cerebral malaria to which children are more vulnerable. Some survivors of cerebral
malaria have an increased risk of neurological and cognitive deficits, behavioural disorders, and epilepsy. Malaria
prophylaxis was shown to improve cognitive function and school performance in clinical trials when compared to
placebo groups.

Epidemiology

Based on documented cases, the WHO estimates that there were 219 million cases of malaria in 2010 resulting in
660,000 deaths. This is equivalent to roughly 2000 deaths every day. A 2012 study estimated the number of
documented and undocumented deaths in 2010 was 1.24 million. The majority of cases (65%) occur in children under 15
years old. Pregnant women are also especially vulnerable: about 125 million pregnant women are at risk of infection
each year. In Sub-Saharan Africa, maternal malaria is associated with up to 200,000 estimated infant deaths yearly.
There are about 10,000 malaria cases per year in Western Europe, and 1300–1500 in the United States.About 900
people died from the disease in Europe between 1993 and 2003. Both the global incidence of disease and resulting
mortality have declined in recent years. According to the WHO, deaths attributable to malaria in 2010 were reduced by
over a third from a 2000 estimate of 985,000, largely due to the widespread use of insecticide-treated nets and
artemisinin-based combination therapies.

Malaria is presently endemic in a broad band around the equator, in areas of the Americas, many parts of Asia, and
much of Africa; however, it is in Sub-Saharan Africa where 85–90% of malaria fatalities occur. An estimate for 2009
reported that countries with the highest death rate per 100,000 of population were Ivory Coast with 86.15, Angola
(56.93) and Burkina Faso (50.66). An estimate for 2010 said the deadliest countries per population were Burkina Faso,
Mozambique and Mali.The Malaria Atlas Project aims to map global endemic levels of malaria, providing a means with
which to determine the global spatial limits of the disease and to assessdisease burden.[83][84] This effort led to the
publication of a map of P. falciparum endemicity in 2010.[85] As of 2010, about 100 countries have endemic malaria.
Every year, 125 million international travellers visit these countries, and more than 30,000 contract the disease.
The geographic distribution of malaria within large regions is complex, and malaria-afflicted and malaria-free areas are
often found close to each other.Malaria is prevalent in tropical and subtropical regions because of rainfall, consistent
high temperatures and high humidity, along with stagnant waters in which mosquito larvae readily mature, providing
them with the environment they need for continuous breeding.In drier areas, outbreaks of malaria have been predicted
with reasonable accuracy by mapping rainfall. Malaria is more common in rural areas than in cities. For example, several
cities in the Greater Mekong Subregion of Southeast Asia are essentially malaria-free, but the disease is prevalent in
many rural regions, including along international borders and forest fringes.In contrast, malaria in Africa is present in
both rural and urban areas, though the risk is lower in the larger cities.
 KLINIK 1 MALAYSIA

Bertepatan dengan gagasan 1Malaysia ‘Rakyat Didahulukan Pencapaian Diutamakan’, 50 buah klinik 1Malaysia telah
dibina dengan peruntukan sebanyak RM10 juta. Klinik 1Malaysia merupakan sebuah projek klinik yang telah dilancarkan
oleh Perdana Menteri Malaysia, Dato' Sri Mohd Najib Tun Abdul Razak di Flet Kampung Kerinchi, Kuala Lumpur pada 7
Januari 2010. Usaha ini merupakan salah satu bukti kerajaan prihatin dengan golongan berpendapatan rendah .

Sebanyak 48 daripada 50 buah klinik 1Malaysia telah beroperasi. Hanya terdapat 3 hingga 4 klinik ini di setiap negeri.
Klinik ini bertujuan memudahkan penjagaan kesihatan golongan miskin bandar di mana mereka, tidak lagi perlu
berkenderaan ke Klinik-klinik Kesihatan yang jauhnya sehingga 10 kilometer dari rumah.

Klinik 1Malaysia dikendalikan oleh pembantu hospital (HA). Kerajaan membenarkan HA memberikan ubat bagi sakit
yang ringan. Antaranya ialah demam, batuk dan menjalani pemeriksaan darah dan tahap kandungan gula.
Bagaimanapun, Klinik ini dipantau oleh Jabatan Kesihatan bagi memastikan segala kemudahan dan bekalan ubat
sentiasa mencukupi. Kes-kes yang di luar bidang perkhidmatan penolong pegawai perubatan atau kes-kes yang perlu
dilihat oleh pegawai perubatan akan dirujuk ke klinik kesihatan atau hospital berdekatan.

OBJEKTIF KLINIK 1MALAYSIA

Menyediakan perkhidmatan rawatan perubatan ringan kepada penduduk setempat.

SKOP PERKHIDMATAN

* Perkhidmatan rawatan ringan seperti demam, batuk, selsema dan penyakit-penyakit ringan yang lain.

* Rawatan susulan kes pesakit kronik yang stabil dan terkawal seperti Diabetes, Darah Tinggi dan Asma.

* Prosedur rawatan ringan seperti mencuci luka dan membuka jahitan

* Membuat notifikasi bagi penyakit berjangkit seperti Demam Denggi.

* Khidmat Nasihat/Pendidikan kesihatan.

MASA OPERASI

• Tujuh hari seminggu

• 10.00 pagi hingga 10.00 malam (termasuk cuti sekolah atau perayaan)

BAYARAN

• Warganegara -RM1

• Bukan Warganegara - RM15

Senarai Klinik 1 Malaysia:

1. Klinik 1Malaysia Kangar, Perlis 6. Klinik 1Malaysia Batu Kawan, Seberang Perai
Selatan,Pulau Pinang
2. Klinik 1Malaysia Bandar Puteri Jaya, , Sungai
Petani,Kedah 7. Klinik 1Malaysia Sungai Ara, Bayan Lepas,Pulau
Pinang
3. Klinik 1Malaysia Taman Kota Kenari,
Kulim,kedah 8. Klinik 1Malaysia Alma Jaya, Bukit
Mertajam,Pulau Pinang
4. Klinik 1Malaysia Jelutong,Pulau Pinang
9. Klinik 1Malaysia Teluk Intan,Perak
5. Klinik 1Malaysia Teluk Air Tawar,
Butterworth,Pulau Pinang
10. Klinik 1Malaysia Bandar Seri Iskandar, Perak 29. Klinik 1Malaysia Taman Megah Ria Johor
Tengah,Perak
30. Klinik 1Malaysia Taman Manis, Kulai,Johor
11. Klinik 1Malaysia Aulong, Taiping,Perak
31. Klinik 1Malaysia Stulang Laut, Johor Baru,Johor
12. Klinik 1Malaysia Bercham,Ipoh,Perak
32. Klinik 1Malaysia Bandar Sri Alam, Johor
13. Klinik 1Malaysia Lembah Subang, Petaling Baru,Johor
Jaya,Selangor
33. Klinik 1Malaysia Taman Seri Lambak,
14. Klinik 1Malaysia Seri Setia, Petaling Kluang,Johor
Jaya,Selangor
34. Klinik 1Malaysia Kempadang, Kuantan,Pahang
15. Klinik 1Malaysia Puchong Intan,Selangor
35. Klinik 1Malaysia Padang Jaya, Kuantan,Pahang
16. Klinik 1Malaysia Kota Kemuning,Shah
Alam,Selangor 36. Klinik 1Malaysia Temerloh, Temerloh,Pahang

17. Klinik 1Malaysia Taman Samuder, Batu 37. Klinik 1Malaysia Bukit Payong,
Caves,Selangor Marang,Terengganu

18. Klinik 1Malaysia Perkasa, Kampung 38. Klinik 1Malaysia Wakaf Baru, Kuala Terengganu
Pandan,Kuala Lumpur
39. Klinik 1Malaysia Binjai, Kemaman,Terengganu
19. Klinik 1Malaysia Kerinchi, Lembah Pantai
40. Klinik 1Malaysia Sri CemerlangKota
20. Klinik 1Malaysia Taman Melati,Kuala Lumpur Bharu,Kelantan

21. Klinik 1Malaysia Intan Baiduri,Kuala Lumpur 41. Klinik 1Malaysia JelawatBachok,Kelantan

22. Klinik 1Malaysia Desa Rejan, Setapak,Kuala 42. Klinik 1Malaysia Pengkalan Batu, Pasir
Lumpur Mas,kelantan

23. Klinik 1Malaysia Taman Rasah Jaya, Negeri 43. Klinik 1Malaysia Bandar Sri Indah Tawau,
Sembilan Tawau,Sabah

24. Klinik 1Malaysia Taman Seremban Jaya, Negeri 44. Klinik 1Malaysia Bundusan Square,Sabah
Sembilan
45. Klinik 1Malaysia Sandakan,Sabah
25. Klinik 1Malaysia Taman Semarak 2,Nilai,Negeri
46. Klinik 1Malaysia Kota Kinabalu,Kota
Sembilan
Kinabalu,Sabah
26. Klinik 1Malaysia Taman Merdeka, Batu
47. Klinik 1Malaysia Jalan Teku, Sibu,Sarawak
Berendam, No 39, Jalan M1, Batu Berendam,Melaka
48. Klinik 1Malaysia Matang Jaya, Kuching,Sarawak
27. Klinik 1Malaysia Bukit Katil, 17,Melaka
49. Klinik 1Malaysia Taman Tunku, Miri,Sarawak
28. Klinik 1Malaysia Sri Pengkalan, Alor Gajah,
Melaka 50. Klinik 1Malaysia Sungai Plan, Bintulu,Sarawak
 MENTERI-MENTERI DI MALAYSIA
YAB DATO' SRI MOHD. NAJIB BIN TUN HAJI ABDUL
RAZAK
Perdana Menteri Merangkap Menteri Kewangan dan
Menteri Pembangunan Wanita, Keluarga dan
Masyarakat,
YAB TAN SRI DATO' HAJI MUHYIDDIN BIN MOHD.
YASSIN
Timbalan Perdana Menteri Merangkap Menteri
Pelajaran,
YB SENATOR DATUK SERI PALANIVEL A/L
K.GOVINDASAMY
Menteri di Jabatan Perdana Menteri,
YB DATO' SRI PETER CHIN FAH KUI
Menteri Tenaga, Teknologi Hijau dan Air,
YB SENATOR TAN SRI DR. KOH TSU KOON
Menteri di Jabatan Perdana Menteri,
YB TAN SRI BERNARD GILUK DOMPOK
Menteri Perusahaan Perladangan dan Komoditi,
YB DATO' SERI MOHAMED NAZRI BIN ABDUL AZIZ
Menteri di Jabatan Perdana Menteri,
YB DATO' SERI HISHAMMUDDIN BIN TUN HUSSEIN
Menteri Dalam Negeri,
YB DATO' SERI UTAMA DR. RAIS BIN YATIM
Menteri Penerangan, Komunikasi dan Kebudayaan,
YB TAN SRI NOR MOHAMED BIN YAKCOP
Menteri di Jabatan Perdana Menteri,
YB DATO' SERI HJ. MOHD SHAFIE BIN HJ. APDAL
Menteri Kemajuan Luar Bandar dan Wilayah,
YB DATO' SERI MOHAMED KHALED BIN NORDIN
Menteri Pengajian Tinggi,
YB DATO' SRI MUSTAPA BIN MOHAMED
Menteri Perdagangan Antarabangsa dan Industri,
YB DATUK SERI PANGLIMA DR. MAXIMUS JOHNITY
ONGKILI
Menteri Sains, Teknologi dan Inovasi,
YB DATO SRI DOUGLAS UGGAH EMBAS
Menteri Sumber Asli dan Alam Sekitar,
YB DATO' SRI DR. NG YEN YEN
Menteri Pelancongan,
YB DATUK SERI HAJI NOH BIN OMAR
Menteri Pertanian dan Industri Asas Tani,
YB DATO' SERI DR. AHMAD ZAHID BIN HAMIDI
Menteri Pertahanan,
YB DATO' SERI SHAZIMAN BIN ABU MANSOR
Menteri Kerja Raya,
YB DATO' SRI LIOW TIONG LAI
Menteri Kesihatan
YB DATO' SRI AHMAD SHABERY BIN CHEEK
Menteri Belia dan Sukan
YB DATUK SERI DR. S. SUBRAMANIAM
Menteri Sumber Manusia,
YB DATO' SRI ISMAIL SABRI BIN YAAKOB
Menteri Perdagangan Dalam Negeri, Koperasi dan
Kepenggunaan,
YB DATO' SERI AHMAD HUSNI BIN MOHAMAD
HANADZLAH
Menteri Kewangan (II),
YB DATO' SERI KONG CHO HA
Menteri Pengangkutan,
YB DATO' SRI ANIFAH BIN AMAN
Menteri Luar Negeri,
YB SENATOR DATO' RAJA NONG CHIK BIN DATO' RAJA
ZAINAL ABIDIN
Menteri Wilayah Persekutuan Dan Kesejahteraan
Bandar,
YB SENATOR MEJAR JENERAL DATO' SERI JAMIL KHIR
BIN BAHAROM (B)
Menteri di Jabatan Perdana Menteri,
YB SENATOR DATO' SRI IDRIS JALA
Menteri di Jabatan Perdana Menteri,
YB DATO' SERI CHOR CHEE HEUNG
Menteri Perumahan dan Kerajaan Tempatan,
SENARAI NAMA TIMBALAN MENTERI
YB TAN SRI DATUK SERI PANGLIMA JOSEPH KURUP
Timbalan Menteri Sumber Asli dan Alam Sekitar,
YB DATUK LIEW VUI KEONG
Timbalan Menteri di Jabatan Perdana Menteri,
YB DATUK DR. HAJI ABD. LATIFF BIN AHMAD
Timbalan Menteri Pertahanan,
YB DATO' JOSEPH SALANG ANAK GANDUM
Timbalan Menteri Penerangan, Komunikasi dan
Kebudayaan,
YB DATUK JOSEPH ENTULU ANAK BELAUN
Timbalan Menteri Kemajuan Luar Bandar dan Wilayah,
YB DATO' WIRA MOHD. JOHARI BIN BAHARUM
Timbalan Menteri Pertanian dan Industri Asas Tani,
YB DATUK WIRA ABU SEMAN BIN HAJI YUSOP
Timbalan Menteri Dalam Negeri,
YB SENATOR DATO' DR. MASHITAH BINTI IBRAHIM
Timbalan Menteri di Jabatan Perdana Menteri,
YB DATO' YONG KHOON SENG
Timbalan Menteri Kerja Raya,
YB DATUK HAJAH ROHANI BINTI ABDUL KARIM
Timbalan Menteri Perdagangan Dalam Negeri, Koperasi
dan Kepenggunaan,
YB DATO' NORIAH BINTI KASNON
Timbalan Menteri Pembangunan Wanita, Keluarga dan
Masyarakat,
YB DATO JACOB DUNGAU SAGAN
Timbalan Menteri Perdagangan Antarabangsa dan
Industri,
YB DATUK IR. DR. WEE KA SIONG
Timbalan Menteri Pelajaran,
YB TUAN JELAING ANAK MERSAT
Timbalan Menteri Pengangkutan,
YB DATUK HAJI FADILLAH BIN YUSOF
Timbalan Menteri Sains, Teknologi dan Inovasi,
YB DATO' TAN LIAN HOE
Timbalan Menteri Perdagangan Dalam Negeri, Koperasi
dan Kepenggunaan,
YB DATO' DEVAMANY A/L S. KRISHNASAMY
Timbalan Menteri di Jabatan Perdana Menteri,
YB DATUK SARAVANAN A/L MURUGAN
Timbalan Menteri Wilayah Persekutuan Dan
Kesejahteraan Bandar,
YB SENATOR TUAN A. KOHILAN PILLAY A/L G. APPU
Timbalan Menteri Luar Negeri,
YB DATO' DR. HOU KOK CHUNG
Timbalan Menteri Pengajian Tinggi,
YB DATO' HAMZAH BIN ZAINUDIN
Timbalan Menteri Perusahaan Perladangan dan
Komoditi,
YB DATO' SAIFUDDIN BIN ABDULLAH
Timbalan Menteri Pengajian Tinggi,
YB DATO' HASAN BIN MALEK
Timbalan Menteri Kemajuan Luar Bandar dan Wilayah,
YB SENATOR DATO' MAZNAH BINTI MAZLAN
Timbalan Menteri Sumber Manusia,
YB DATUK ABD RAHIM BIN BAKRI SENARAI NAMA DAN ALAMAT MENTERI BESAR DAN
KETUA MENTERI MENGIKUT SUSUNAN KEKANANAN
Timbalan Menteri Pengangkutan, RAJA-RAJA DAN TYT YANG DI PERTUA NEGERI
YB SENATOR DATO' DR. AWANG ADEK HUSSEIN

Timbalan Menteri Kewangan, YAB DATO' SRI DIRAJA HAJI ADNAN BIN HAJI YAAKOB
YB DATUK ROSNAH BINTI HAJI ABDUL RASHID SHIRLIN Menteri Besar Pahang,
Timbalan Menteri Kesihatan, YAB DATO' SERI DIRAJA DR. ZAMBRY BIN ABDUL
KADIR
YB DR. HAJI MOHD PUAD BIN ZARKASHI
Menteri Besar Perak,
Timbalan Menteri Pelajaran,
YAB DATO' SERI AHMAD BIN SAID
YB DATO' RAZALI HJ. IBRAHIM
Menteri Besar Terengganu,
Timbalan Menteri Belia dan Sukan,
YAB DATO' SERI DR. MD. ISA BIN SABU
YB DATO' MUKHRIZ BIN TUN DR. MAHATHIR
Menteri Besar Perlis,
Timbalan Menteri Perdagangan Antarabangsa dan
Industri, YAB TAN SRI DATO' SERI ABDUL KHALID BIN IBRAHIM
YB DATUK HAJI AHMAD BIN HAJI MASLAN Menteri Besar Selangor,
Timbalan Menteri di Jabatan Perdana Menteri, YAB DATO' SERI UTAMA HAJI MOHAMAD BIN HAJI
HASAN
YB DATO' LEE CHEE LEONG
Menteri Besar Negeri Sembilan,
Timbalan Menteri Dalam Negeri,
YAB DATO' HAJI ABDUL GHANI BIN OTHMAN
YB DATO DR. JAMES DAWOS MAMIT
Menteri Besar Johor,
Timbalan Menteri Pelancongan,
YAB TUAN GURU DATO' BENTARA SETIA HAJI NIK
YB SENATOR DATO' IR. DONALD LIM SIANG CHAI
ABDUL AZIZ BIN NIK MAT
Timbalan Menteri Kewangan,
Menteri Besar Kelantan,
YB SENATOR DATUK MAGLIN DENNIS D'CRUZ
YAB DATO' SERI USTAZ AZIZAN BIN ABDUL RAZAK
Timbalan Menteri Penerangan, Komunikasi dan
Menteri Besar Kedah,
Kebudayaan,
YAB TAN SRI PEHIN SRI HAJI ABDUL TAIB MAHMUD
YB SENATOR TUAN GAN PING SIEU
Ketua Menteri Sarawak,
Timbalan Menteri Belia dan Sukan,
YAB TUAN LIM GUAN ENG
YB DATUK RICHARD RIOT ANAK JAEM
Ketua Menteri Pulau Pinang,
Timbalan Menteri Luar Negeri,
YAB DATUK SERI HAJI MOHD. ALI BIN MOHD. RUSTAM
YB DATUK CHUA TEE YONG
Ketua Menteri Melaka,
Timbalan Menteri Pertanian dan Industri Asas Tani,
YAB DATUK SERI PANGLIMA MUSA BIN HAJI AMAN

Ketua Menteri Sabah,

 MAKLUMAT BERKAITAN KEMENTERIAN KESIHATAN MALAYSIA(KKM)

Objektif kkm

Untuk membantu seseorang individu untuk mencapai dan mengekalkan satu taraf kesihatan bagi membolehkannya
menjalankan kehidupan ekonomi dan sosial yang produktif

Ini boleh dicapai dengan menyediakan perkhidmatan bercorak penggalakan, pencegahan, rawatan dan pemulihan yang
cekap, sesuai dan berkesan dengan memberi penekanan kepada golongan-golongan yang kurang bernasib baik.

Visi dan Misi

VISI:Negara menggembleng tenaga ke arah kesihatan yang lebih baik.

MISI:Misi Kementerian Kesihatan adalah untuk menerajui dan berusaha bersama-sama:

i. untuk memudahkan dan membolehkan rakyat:

 mencapai sepenuhnya potensi mereka dalam kesihatan

 menghargai kesihatan sebagai aset paling berharga
 mengambil tanggungjawab dan tindakan positif demi kesihatan mereka

ii. untuk memastikan sistem kesihatan berkualiti tinggi iaitu:

 mengutamakan pelanggan
 saksama
 tidak membebankan
 cekap
 wajar mengikut teknologi
 boleh disesuaikan mengikut persekitaran
 inovatif

iii. dengan menekankan:

 sifat penyayang, profesionalisme dan kerja berpasukan

 sifat menghormati maruah insan
 penglibatan masyarakat

Budaya Korporat

LOGO

MOTO

Kami Sedia Membantu

Kami - Semua anggota Kementerian Kesihatan Malaysia bekerja sebagai satu pasukan untuk mencapai matlamat yang
sama.

Sedia - Sentiasa bersiap sedia untuk memberi perkhidmatan secara profesional.

Membantu - Ikhlas semasa memberi bantuan dan menjalankan tugas.

NILAI-NILAI TERAS

Penyayang

Kami komited untuk menerima pelanggan dengan sikap ramah mesra dan penuh perhatian. Kami bersedia memberi
layanan dengan bersopan santun, responsif dan menghormati hak individu. Kami bertanggungjawab memberi
perkhidmatan yang mesra pelanggan.

Profesionalisme

Kami komited untuk memberi perkhidmatan yang terbaik merangkumi etika dan taraf kerja yang dikehendaki serta
prinsip anggota yang bertanggungjawab. Kami percaya dalam memberikan perkhidmatan cemerlang dan sentiasa
bersedia memenuhi harapan masyarakat.

Kerja Berpasukan

Kami komited untuk bekerja sebagai satu pasukan dengan harmoni bagi mencapai matlamat yang sama.

Bajet 2013 utk kesihatan

Kesihatan Asas Kesejahteraan

Kerajaan akan terus memastikan rakyat dapat menikmati perkhidmatan kesihatan yang memuaskan. Bagi tahun 2013,
Kerajaan memperuntukkan sebanyak 19.3 bilion ringgit untuk perkhidmatan mengurus dan pembangunan.

Pembukaan Klinik 1Malaysia telah mendapat sambutan baik dan memberi manfaat dalam meringankan kos rawatan
selain memudahkan akses bagi mendapatkan rawatan. Justeru, Kerajaan akan memperuntukkan 20 juta ringgit bagi
membuka tambahan 70 klinik pada tahun 2013. Klinik 1Malaysia juga akan mula menyediakan perkhidmatan ujian
kolesterol dan glukosa serta ujian urin kepada mereka yang memerlukan. Selain itu, sebanyak 100 juta ringgit akan
diperuntukkan untuk membaik pulih 350 klinik di seluruh negara, di samping menambah 150 buah mesin dialisis di pusat
hemodialisis Kerajaan seluruh negara.
 Penyakit Tangan, Kaki Dan Mulut (HFMD)

Penyakit HFMD disebabkan oleh virus yang dikenali sebagai enterovirus meliputi Coxsackie Virus A16 (Cox A16) dan
Enterovirus 71 (EV 71). Penularan penyakit/virus HFMD adalah melalui sentuhan langsung dengan cecair hidung, air liur,
lepuh (blister) dan najis kanak-kanak yang dijangkiti serta sentuhan pada permukaan dan alatan permainan yang
tercemar dengan virus HFMD. Mereka yang dijangkiti akan menunjukkan satu atau lebih tanda seperti demam, luka
(ulcer) di mulut, ruam atau lepuh di tapak tangan dan kaki. HFMD selalunya menyebabkan jangkitan ringan dan sembuh
dengan sendiri. Namun begitu, segelintir jangkitan HFMD yang disebabkan oleh jangkitan EV71 boleh menyebabkan
komplikasi seperti radang otak dan jantung.

Bagi memastikan keberkesanan langkah-langkah kawalan dan pencegahan yang diambil, Kementerian Kesihatan
Malaysia ingin mengingatkan orang ramai bahawa:

i) Langkah pencegahan terbaik adalah menjaga kebersihan diri dan persekitaran. Penularan jangkitan HFMD
sangat berkait rapat dengan amalan kebersihan diri dan persekitaran di mana ia mudah berlaku di tempat sesak serta
mutu kebersihan yang rendah.

ii) Ibu bapa atau penjaga perlu membawa kanak-kanak dengan gejala HFMD mendapatkan rawatan dan tidak
membawa kanak-kanak tersebut ke tempat awam termasuk sekolah dan pusat jagaan kanak-kanak.

iii) Pengurus pusat jagaan kanak-kanak perlu menjalankan aktiviti pembersihan premis dan saringan terhadap
kanak-kanak di bawah jagaan mereka sepertimana yang disarankan dalam ‘Garis Panduan Pengendalian Kanak-Kanak di
Taska dan Prasekolah’ serta ‘Pelan Tindakan Bersepadu Bagi Mencegah Dan Mengawal Penyakit Tangan, Kaki Dan
Mulut’.

_____________________________________________________________________________________________

Institut Penyelidikan Perubatan

Kementerian Kesihatan Malaysia

Jalan Pahang 50588

Kuala Lumpur

Institut Penyelidikan Perubatan (IMR)

Institut Penyelidikan Perubatan(IMR) berfungsi sebagai pusat penyelidikan yang menyediakan perkhidmatan diagnostik
selain membekalkan kemahiran dan perkhidmatan konsultasi mengenai masalah kesihatan serta penyakit berjangkit.
IMR juga bertindak sebagai Pusat Serantau SEAMEO-TROPMED bagi Mikrobiologi, Parasitologi dan Entornologi, Pusat
Serantau Kesihatan Sedunia (WHO) bagi Penyelidikan dan Latihan dalam Penyakit-Penyakit Tropika. IMR juga telah
menjadi Makmal Rujukan Kebangsaan bagi pelbagai jenis penyakit berjangkit seperti Sindrom Pernafasan Akut Teruk
(SARS) dan selsema burung. Selain itu, IMR menjalankan ujian diagnostik lain seperti ujian bagi demam denggi berdarah,
penyakit tangan, mulut dan kaki (HFMD) dan lain-lain.
 Pap Smear

Apakah itu ujian Pap Smear?

•merupakan suatu ujian untuk memeriksa kesihatan servik.

•Ia boleh menyelamatkan nyawa anda

•Ia adalah satu saringan untuk mengesan keadaan pra-kanser (sebelum terjadi) iaitu terdapat sel serviks luar biasa yang
boleh mengakibatkan kanser.

•Ia adalah sempena orang yang pertama menjumpai cara ini pada tahun 1940 iaitu DR. GEORGE PAPANICOLAOU.

•Ia adalah satu prosidur yang mudah dimana sedikit sel diambil dari servik dan dihantar ke makmal untuk kajian.

•Tidak perlu ubat atau bius.

•Mengambil masa beberapa minit sahaja.

Adakah ujian itu menyakitkan?

•Tidak menyakitkan.

•Jika anda merasa tegang semasa prosidur dijalankan, anda mungkin rasa tidak selesa, cuba relak dan tarik nafas
panjang.

Siapakah yang harus menjalani ujian tersebut?

Wanita berumur diantara 20 - 65 tahun, mereka yang pernah atau aktif dalam hubungan seksual.

Siapakah yang akan menjalankan ujian tersebut?

Doktor atau jururawat yang terlatih akan menjalankannya.

Apakah yang sebenar berlaku semasa ujian tersebut dilakukan?

•Tanggalkan seluar dalam.

•Berbaring di atas katil.

•Doktor atau jururawat akan memasukkan alat kecil yang dinamakan spekulum ke dalam vagina dengan lembut supaya
servik boleh dilihat.

•Sejenis kayu 'wooden spatula' dan berus yang kecil 'cytobrush' dimasukkan ke dalam pangkal rahim (keseluruhan servik
360o) untuk mengambil sedikit sel.

•Sampel ini disapu di atas slaid dan dihantar ke makmal untuk diperiksa di bawah mikroskopi dimana lapuran akan
dibuat.

•Ujian ini mengambil masa beberapa minit sahaja.

Apakah persediaan awal yang patut dilakukan?

•Ujian ini tidak dapat dijalankan semasa anda kedatangan haid.

•Pastikan dapat tarikh temujanji sebelum atau selepas haid.

•Waktu yang sesuai adalah pertengahan atau selepas 10 hari kitaran haid.

Bagaimana dengan hubungan seksual sebelum ujian?

•Anda tidak digalakkan melakukan hubungan seks 24 jam sebelum ujian dijalankan kerana ia menyebabkan keputusan
yang tidak tepat.

•Jangan lakukan 'duoche' atau gunakan spermicid, perancang keluarga, kaedah halangan atau penggunaan jelly
'lubricant' 2 hari sebelum ujian dijalankan.

•Bahan kimia yang terdapat dalam bahan tersebut mungkin boleh memberi kesan kepada kualiti sampel.

Bilakah saya mendapat keputusannya?

•Bila anda melakukan ujian tersebut, anda akan diberitahu masa dan tempat untuk mendapatkan keputusan..

•Biasanya dalam 3 minggu hingga 3 bulan bergantung kepada beban kerja makmal dan klinik tersebut.

Berapa kerap saya perlu membuat ujian Pap Smear?

•Sekiranya anda berumur antara 20 - 65 tahun, pernah atau aktif dalam hubungan seksual, anda digalakkan untuk
menjalani ujian ini setiap tahun selama 2 tahun.

•Sekiranya keputusan itu negatif, anda digalakkan mengulangi setiap 3 tahun sekali.

Dimanakah saya boleh mendapatkan ujian tersebut?

•Di semua klinik dan hospital kerajaan

•Di klinik/hospital swasta

•Federation of Family Planning Association Of Malaysia (FFPAM)

•Lembaga Penduduk Perancang Keluarga Negara (LPPKN)

Apakah makna keputusan tersebut?

•Keputusan yang normal bermaksud tiada keadaan luarbiasa atau masalah yang dikesan.

•Keputusan yang luarbiasa bermaksud, anda dan anggota kesihatan perlu berunding untuk rawatan selanjutnya.

•Keputusan luarbiasa adalah seperti berikut :

 Kesan mikroorganisma atau virus (Jangkitan penyakit kelamin) boleh dikesan pada smear.
 Sel-sel itu mungkin berubah akibat jangkitan (perubahan ini sementara dan setempat ('benign' - bukan menunju
 Sel-sel di servik mungkin menunjukkan perubahan seperti keadaan pra-kanser (sebelum berlaku kanser).

Apa yang patut dilakukan seterusnya :

 Rawatan susulan
 Ulangi ujian pap smear dalam 3-6 bulan
 Jalani pemeriksaan kolposkopi

Apakah itu kolposkopi?

•Satu alat diagnostik yang membolehkan doktor melihat saiz dan kawasan servik yang luarbiasa.

 Ia adalah kaca pembesar yang membolehkan kkan kanser supaya doktor melihat dengan jelas perubahan pada servik.

•Alat ini tidak dimasukkan ke dalam tubuh badan.

•Kurang menyakitkan.
•Sesetengah orang merasa tidak selesa.

•Sampel tisu biopsy mungkin diambil untuk ujian selanjutnya.

•Kawasan itu mungkin dirawat dengan 'electro coagulation', 'laser' atau 'cryosurgery' untuk memusnahkan tisu-tisu yang
terlibat.

Apakah persediaan awal yang patut saya lakukan?

•Tidak boleh dilakukan semasa kedatangan haid.

•Pastikan mendapat tarikh temujanji sebelum atau selepas haid.

•Waktu yang sesuai ialah pertengahan atau selepas 10 hari kitaran haid.

TUBERCULOSIS

Overview

Tuberculosis (TB) is caused by a bacterium calledMycobacterium tuberculosis. The bacteria usually attack the lungs, but
TB bacteria can attack any part of the body such as the kidney, spine, and brain. If not treated properly, TB disease can
be fatal.

Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions exist: latent TB infection and
TB disease. Both latent TB infection and TB disease can be treated. Learn more about the difference between latent TB
infection and TB disease.

Treatment of tuberculosis (TB)

Treatment for Latent TB Infection:

People with latent TB infection have TB bacteria in their bodies, but they are not sick because the bacteria are not
active. People with latent TB infection do not have symptoms, and they cannot spread TB bacteria to others. However, if
TB bacteria become active in the body and multiply, the person will go from having latent TB infection to being sick with
TB disease. For this reason, people with latent TB infection are often prescribed treatment to prevent them from
developing TB disease. Treatment of latent TB infection is essential for controlling and eliminating TB in the United
States.

Because there are less bacteria in a person with latent TB infection, treatment is much easier.Four regimens are
approved for the treatment of latent TB infection. The medications used to treat latent TB infection include:

• isoniazid (INH) • rifapentine (RPT)

• rifampin (RIF)

Certain groups of people (such as people with weakened immune systems) are at very high risk of developing TB disease
once infected with TB bacteria. Every effort should be made to begin appropriate treatment and to ensure completion
of the entire course of treatment for latent TB infection.

Treatment for TB Disease

TB bacteria become active (multiplying in the body) if the immune system can't stop them from growing. When TB
bacteria are active, this is called TB disease. TB disease will make a person sick. People with TB disease may spread the
bacteria to people with whom they spend many hours.
TB disease can be treated by taking several drugs for 6 to 9 months. There are 10 drugs currently approved by the U.S.
Food and Drug Administration (FDA) for treating TB. Of the approved drugs, the first-line anti-TB agents that form the
core of treatment regimens include:

• isoniazid (INH) • ethambutol (EMB)

• rifampin (RIF) • pyrazinamide (PZA)

Regimens for treating TB disease have an initial phase of 2 months, followed by a choice of several options for the
continuation phase of either 4 or 7 months (total of 6 to 9 months for treatment). Learn more about the continuation
phase of treatment.

It is very important that people who have TB disease finish the medicine, taking the drugs exactly as prescribed. If they
stop taking the drugs too soon, they can become sick again; if they do not take the drugs correctly, the TB bacteria that
are still alive may become resistant to those drugs. TB that is resistant to drugs is harder and more expensive to treat.

Treatment Completion

Treatment completion is determined by the number of doses ingested over a given period of time. Although basic TB
regimens are broadly applicable, there are modifications that should be made under special circumstances (such as
people with HIV infection, drug resistance, pregnancy, or treatment of children).
 Anesthetic

Not to be confused with aesthetics.

An anesthetic (American English) (or anaesthetic, (Commonwealth English) see spelling differences) is a drug that
causesanesthesia—reversible loss of sensation. They contrast with analgesics (painkillers), which relieve pain without
eliminating sensation. These drugs are generally administered to facilitate surgery. A wide variety of drugs are used in
modern anesthetic practice. Many are rarely used outside of anesthesia, although others are used commonly by all
disciplines. Anesthetics are categorized into two classes:general anesthetics, which cause a reversible loss of
consciousness, and local anesthetics, which cause a reversible loss of sensation for a limited region of the body while
maintaining consciousness. Combinations of anesthetics are sometimes used for their synergistic and additive
therapeutic effects. Adverse effects, however, may also be increased.

Local anesthetics

Each of the local anesthetics have the suffix "-caine" in their names.

• procaine • bupivacaine

• amethocaine • levobupivacaine

• cocaine • ropivacaine

• lidocaine (also known as Lignocaine) • mepivacaine

• prilocaine • dibucaine

Local anesthetics are agents that prevent transmission of nerve impulses without causing unconsciousness. They act by
binding to fastsodium channels from within (in an open state). Local anesthetics can be either ester or amide based.

Ester local anesthetics (e.g., procaine, amethocaine, cocaine,benzocaine,tetracaine) are generally unstable in solution
and fast-acting, and allergic reactions are common.

Amide local anesthetics (e.g., lidocaine, prilocaine, bupivicaine, levobupivacaine, ropivacaine, mepivacaine, dibucaine
and etidocine) are generally heat-stable, with a long shelf life (around 2 years). They have a slower onset and longer
half-life than ester anesthetics, and are usually racemic mixtures, with the exception of levobupivacaine (which is S(-) -
bupivacaine) and ropivacaine (S(-)-ropivacaine). These agents are generally used within regional and epidural or spinal
techniques, due to their longer duration of action, which provides adequate analgesia for surgery, labor, and
symptomatic relief.

Only preservative-free local anesthetic agents may be injected intrathecally.

General anesthetics

1)Inhaled agents

• Desflurane • Methoxyflurane

• Enflurane • Nitrous oxide

• Halothane • Sevoflurane

• Isoflurane • Xenon (rarely used)

Volatile agents are specially formulated organic liquids that evaporate readily into vapors, and are given by inhalation
for induction and/or maintenance of general anesthesia. Nitrous oxide and xenon are gases at room temperature rather
than liquids, so they are not considered volatile agents. The ideal anesthetic vapor or gas should be non-flammable, non-
explosive, and lipid-soluble. It should possess low blood gas solubility, have no end-organ (heart, liver, kidney) toxicity or
side-effects, should not be metabolized, and should not be an irritant to the respiratory pathways of the patient.

No anesthetic agent currently in use meets all these requirements. The agents in widespread current use are isoflurane,
desflurane,sevoflurane, and nitrous oxide. Nitrous oxide is a common adjuvant gas, making it one of the most long-lived
drugs still in current use. Because of its low potency, it cannot produce anesthesia on its own but is frequently combined
with other agents. Halothane, an agent introduced in the 1950s, has been almost completely replaced in modern
anesthesia practice by newer agents because of its shortcomings.Partly because of its side effects, enflurane never
gained widespread popularity.

In theory, any inhaled anesthetic agent can be used for induction of general anesthesia. However, most of the
halogenated anesthetics are irritating to the airway, perhaps leading to coughing, laryngospasm and overall difficult
inductions. For this reason, the most frequently used agent for inhalational induction is sevoflurane[citation needed]. All
of the volatile agents can be used alone or in combination with other medications to maintain anesthesia (nitrous oxide
is not potent enough to be used as a sole agent).

Volatile agents are frequently compared in terms of potency, which is inversely proportional to the minimum alveolar
concentration. Potency is directly related to lipid solubility. This is known as the Meyer-Overton hypothesis. However,
certain pharmacokinetic properties of volatile agents have become another point of comparison. Most important of
those emergence from the anesthetic state upon discontinuing their administration. In fact, newer volatile agents (e.g.,
sevoflurane, desflurane) have been popular not due to their potency (minimum alveolar concentration), but due to their
versatility for a faster emergence from anesthesia, thanks to their lower blood–gas partition coefficient.

2)Intravenous agents (non-opioid)

While there are many drugs that can be used intravenously to produce anesthesia or sedation, the most common are:

• Barbiturates • Diazepam

• Amobarbital (trade name: Amytal) • Lorazepam

• Methohexital (trade name: Brevital) • Midazolam

• Thiamylal (trade name: Surital) • Etomidate

• Thiopental (trade name: Penthothal, referred to • Ketamine

as thiopentone in the UK)
• Propofol
• Benzodiazepines
The two barbiturates mentioned above, thiopental and methohexital, are ultra-short-acting, and are used to induce and
maintain anesthesia. However, though they produce unconsciousness, they provide no analgesia (pain relief) and must
be used with other agents.Benzodiazepines can be used for sedation before or after surgery and can be used to induce
and maintain general anesthesia.When benzodiazepines are used to induce general anesthesia, midazolam is
preferred.Benzodiazepines are also used for sedation during procedures that do not require general anesthesia.Like
barbiturates, benzodiazepines have no pain-relieving properties. Propofol is one of the most commonly used
intravenous drugs employed to induce and maintain general anesthesia.It can also be used for sedation during
procedures or in the ICU.Like the other agents mentioned above, it renders patients unconscious without producing pain
relief.[3] Because of its favorable physiological effects, "etomidate has been primarily used in sick patients".Ketamine is
infrequently used in anesthesia because of the unpleasant experiences that sometimes occur on emergence from
anesthesia, which include "vivid dreaming, extracorporeal experiences, and illusions."However, like etomidate it is
frequently used in emergency settings and with sick patients because it produces fewer adverse physiological
effects.Unlike the intravenous anesthetic drugs previously mentioned, ketamine produces profound pain relief, even in
doses lower than those that induce general anesthesia.[3] Also unlike the other anesthetic agents in this section,
patients who receive ketamine alone appear to be in a catalepticstate, unlike other states of anesthesia that resemble
normal sleep. Ketamine-anesthetized patients have profound analgesia but keep their eyes open and maintain many
reflexes.
Neonatal and infant neurotoxicity concerns

Concerns have been raised as to the safety of general anesthetics, in particular ketamine and isoflurane in neonates and
young children due to significant neurodegeneration. The risk of neurodegeneration is increased in combination of these
agents with nitrous oxide and benzodiazepines such as midazolam. This has led to the FDA and other bodies to takes
steps to investigate these concerns.[5] These concerns have arisen from animal studies involving rats and non-human
primates. Research has found that anesthetics which enhance GABA or block NMDA can precipitate neuronal cell death.
The developing central nervous system is most vulnerable to these potential neurotoxic effects during the last trimester
of pregnancy and shortly after birth[citation needed]. Melatonin, a free oxygen radical scavenger and indirect
antioxidant is known to reduce the toxicity of a range of drugs has been found in a rat study to reduce the neurotoxicity
of anesthetic agents to the early developing brain.[6] Recent research in animals has found that all sedatives and
anesthetics cause extensive neurodegeneration in the developing brain. There is also some evidence in humans that
surgery and exposure to anesthetics in the early developmental stages causes persisting learning deficits.

3)Intravenous opioid analgesic agents

While opioids can produce unconsciousness, they do so unreliably and with significant side effects.So, while they are
rarely used to induce anesthesia, they are frequently used along with other agents such as intravenous non-opioid
anesthetics or inhalational anesthetics. Furthermore, they are used to relieve pain of patients before, during, or after
surgery. The following opioids have short onset and duration of action and are frequently used during general
anesthesia:

• Alfentanil • Hydromorphone

• Fentanyl • Levorphanol

• Remifentanil • Meperidine, also called pethidine in the UK,

New Zealand, Australia and other countries
• Sufentanil (Not available in the UK)
• Methadone
The following agents have longer onset and duration of
action and are frequently used for post-operative pain • Morphine
relief:
• Nalbuphine
• Buprenorphine
• Oxycodone, (not available intravenously in U.S.)
• Butorphanol
• Oxymorphone
• Diamorphine, (diacetyl morphine, also known as
heroin, not available in U.S.) • Pentazocine

Muscle relaxants

@ Neuromuscular blocking drugs

Muscle relaxants do not render patients unconscious or relieve pain. Instead, they are sometimes used after a patient is
rendered unconscious (induction of anesthesia) to facilitate intubation or surgery by paralyzing skeletal muscle.

• Depolarizing muscle relaxants • Short acting

• Succinylcholine (also known as suxamethonium • Mivacurium

in the UK, New Zealand, Australia and other countries,
"Celokurin" or "celo" for short in Europe) • Rapacuronium

• Decamethonium • Intermediate acting

• Non-depolarizing muscle relaxants • Atracurium

• Cisatracurium • Gallamine

• Rocuronium • Metocurine

• Vecuronium • Pancuronium

• Long acting • Pipecuronium

• Alcuronium • Tubocurarine

• Doxacurium

Adverse effects

1)Depolarizing Muscle Relaxants i.e. Suxamethonium

•Hyperkalemia – A small rise of 0.5 mmol/l occurs normally, this is of little consequence unless potassium is already
raised such as in renal failure

•Hyperkalemia – Exaggerated potassium release in burn patients (occurs from 24 hours after injury, lasting for up to 2
years), neuromuscular disease and paralyzed (quadraplegic, paraplegic) patients. The mechanism is reported to be
through upregulation of acetylcholine receptors in those patient populations with increased efflux of potassium from
inside muscle cells. May cause life threatening arrhythmia

•Muscle aches, commoner in young muscular patients who mobilize soon after surgery

•Bradycardia, especially if repeat doses are given

•Malignant hyperthermia, a potentially life threatening condition in susceptible patients

•Suxamethonium Apnea, a rare genetic condition leading to prolonged duration of neuromuscular blockade, this can
range from 20 minutes to a number of hours. Not dangerous as long as it is recognized and the patient remains
intubated and sedated, there is the potential for awareness if this does not occur.

•Anaphylaxis

2)Non-depolarizing Muscle Relaxants

•Histamine release e.g. Atracurium & Mivacurium

•Anaphylaxis

Another potentially disturbing complication where neuromuscular blockade is employed is 'anesthesia awareness'. In
this situation, patients paralyzed may awaken during their anesthesia, due to an inappropriate decrease in the level of
drugs providing sedation and/or pain relief. If this fact is missed by the anesthesia provider, the patient may be aware of
his surroundings, but be incapable of moving or communicating that fact. Neurological monitors are increasingly
available that may help decrease the incidence of awareness. Most of these monitors use proprietary algorithms
monitoring brain activity via evoked potentials. Despite the widespread marketing of these devices many case reports
exist in which awareness under anesthesia has occurred despite apparently adequate anesthesia as measured by the
neurologic monitor.[citation needed]

Intravenous reversal agents

• Flumazenil, reverses the effects of benzodiazepines

• Naloxone, reverses the effects of opioids

• Neostigmine, helps reverse the effects of non-depolarizing muscle relaxants

• Sugammadex, new agent that is designed to bind Rocuronium therefore terminating its action
 HIV

What are HIV and AIDS?

HIV is the human immunodeficiencyvirus. It is the virus that can lead toacquired immune deficiencysyndrome, or AIDS.
CDC estimates that about 56,000 people in the United States contracted HIV in 2006.

There are two types of HIV, HIV-1 and HIV-2. In the United States, unless otherwise noted, the term “HIV” primarily
refers to HIV-1.

Both types of HIV damage a person’s body by destroying specific blood cells, called CD4+ T cells, which are crucial to
helping the body fight diseases.

Within a few weeks of being infected with HIV, some people develop flu-like symptoms that last for a week or two, but
others have no symptoms at all. People living with HIV may appear and feel healthy for several years. However, even if
they feel healthy, HIV is still affecting their bodies. All people with HIV should be seen on a regular basis by a health care
provider experienced with treating HIV infection. Many people with HIV, including those who feel healthy, can benefit
greatly from current medications used to treat HIV infection. These medications can limit or slow down the destruction
of the immune system, improve the health of people living with HIV, and may reduce their ability to transmit HIV.
Untreated early HIV infection is also associated with many diseases including cardiovascular disease, kidney disease,
liver disease, and cancer. Support services are also available to many people with HIV. These services can help people
cope with their diagnosis, reduce risk behavior, and find needed services.

AIDS is the late stage of HIV infection, when a person’s immune system is severely damaged and has difficulty fighting
diseases and certain cancers. Before the development of certain medications, people with HIV could progress to AIDS in
just a few years. Currently, people can live much longer - even decades - with HIV before they develop AIDS. This is
because of “highly active” combinations of medications that were introduced in the mid 1990s.

No one should become complacent about HIV and AIDS. While current medications can dramatically improve the health
of people living with HIV and slow progression from HIV infection to AIDS, existing treatments need to be taken daily for
the rest of a person’s life, need to be carefully monitored, and come with costs and potential side effects. At this time,
there is no cure for HIV infection. Despite major advances in diagnosing and treating HIV infection, in 2007, 35,962 cases
of AIDS were diagnosed and 14,110 deaths among people living with HIV were reported in the United States.

Where did HIV come from?

Scientists identified a type of chimpanzee in West Africa as the source of HIV infection in humans. They believe that the
chimpanzee version of the immunodeficiency virus (called simian immunodeficiency virus or SIV) most likely was
transmitted to humans and mutated into HIV when humans hunted these chimpanzees for meat and came into contact
with their infected blood. Over decades, the virus slowly spread across Africa and later into other parts of the world.

HIV-2

In 1986, a second type of HIV, called HIV-2, was isolated from AIDS patients in West Africa. HIV-2 has the same modes of
transmission as HIV-1 and is associated with similar opportunistic infections and AIDS. In persons infected with HIV-2,
immunodeficiency seems to develop more slowly and to be milder, and those with HIV-2 are comparatively less
infectious early in the course of infection. As the disease advances, HIV-2 infectiousness seems to increase; however,
compared with HIV-1, the duration of this increased infectiousness is shorter.

HIV-2 infections are predominantly found in Africa. West African nations with a prevalence of HIV-2 of more than 1% in
the general population are Cape Verde, Côte d'Ivoire (Ivory Coast), Gambia, Guinea-Bissau, Mali, Mauritania, Nigeria,
and Sierra Leone. Other West African countries reporting HIV-2 are Benin, Burkina Faso, Ghana, Guinea, Liberia, Niger,
São Tomé, Senegal, and Togo. Angola and Mozambique are other African nations where the prevalence of HIV-2 is more
than 1%.
The first case of HIV-2 infection in the United States was diagnosed in 1987. Since then, the Centers for Disease Control
and Prevention (CDC) has worked with state and local health departments to collect demographic, clinical, and
laboratory data on persons with HIV-2 infection.

How is HIV spread?

You may have heard rumors or myths about how HIV is transmitted. Learn the facts by reading our questions and
answers about HIV Transmission.

HIV is spread primarily by:

• Not using a condom when having sex with a person who has HIV. All unprotected sex with someone who has HIV
contains some risk. However:

 Unprotected anal sex is riskier than unprotected vaginal sex.

 Among men who have sex with other men, unprotected receptive anal sex is riskier than unprotected insertive
anal sex.

• Having multiple sex partners or the presence of other sexually transmitted diseases (STDs) can increase the risk
of infection during sex. Unprotected oral sex can also be a risk for HIV transmission, but it is a much lower risk than anal
or vaginal sex.
• Sharing needles, syringes, rinse water, or other equipment used to prepare illicit drugs for injection.

• Being born to an infected mother—HIV can be passed from mother to child during pregnancy, birth, or breast-
feeding.

Less common modes of transmission include:

• Being “stuck” with an HIV-contaminated needle or other sharp object. This risk pertains mainly to healthcare
workers.

• Receiving blood transfusions, blood products, or organ/tissue transplants that are contaminated with HIV. This
risk is extremely remote due to the rigorous testing of the U.S. blood supply and donated organs/tissue.

• HIV may also be transmitted through unsafe or unsanitary injections or other medical or dental practices.
However, the risk is also remote with current safety standards in the U.S.

• Eating food that has been pre-chewed by an HIV-infected person. The contamination occurs when infected
blood from a caregiver’s mouth mixes with food while chewing. This appears to be a rare occurrence and has only been
documented among infants whose caregiver gave them pre-chewed food.

• Being bitten by a person with HIV. Each of the very small number of cases has included severe trauma with
extensive tissue damage and the presence of blood. There is no risk of transmission if the skin is not broken.

• Contact between broken skin, wounds, or mucous membranes and HIV-infected blood or blood-contaminated
body fluids. These reports have also been extremely rare.

• There is an extremely remote chance that HIV could be transmitted during “French” or deep, open-mouth
kissing with an HIV-infected person if the HIV-infected person’s mouth or gums are bleeding.

• Tattooing or body piercing present a potential risk of HIV transmission, but no cases of HIV transmission from
these activities have been documented. Only sterile equipment should be used for tattooing or body piercing.

• There have been a few documented cases in Europe and North Africa where infants have been infected by
unsafe injections and then transmitted HIV to their mothers through breastfeeding. There have been no documented
cases of this mode of transmission in the U.S.
HIV cannot reproduce outside the human body. It is not spread by:

• Air or water.

• Insects, including mosquitoes. Studies conducted by CDC researchers and others have shown no evidence of HIV
transmission from insects.

• Saliva, tears, or sweat. There is no documented case of HIV being transmitted by spitting.

• Casual contact like shaking hands or sharing dishes.

• Closed-mouth or “social” kissing.

All reported cases suggesting new or potentially unknown routes of transmission are thoroughly investigated by state
and local health departments with assistance, guidance, and laboratory support from CDC.

How do HIV tests work?

The most commonly used HIV tests detect HIV antibodies – the substances the body creates in response to becoming
infected with HIV. There are tests that look for HIV's genetic material or proteins directly; these may also be used to find
out if someone has been infected with HIV.

It can take some time for the immune system to produce enough antibodies for the antibody test to detect, and this
“window period” between infection with HIV and the ability to detect it with antibody tests can vary from person to
person. During this time, HIV viral load and the likelihood of transmitting the virus to sex or needle-sharing partners may
be very high. Most people will develop detectable antibodies that can be detected by the most commonly used tests in
the United States within 2 to 8 weeks (the average is 25 days) of their infection. Ninety-seven percent (97%) of persons
will develop detectable antibodies in the first 3 months. Even so, there is a small chance that some individuals will take
longer to develop detectable antibodies. Therefore, a person should consider a follow-up test more than three months
after their last potential exposure to HIV. In extremely rare cases, it can take up to 6 months to develop antibodies to
HIV.

Conventional HIV tests are sent to a laboratory for testing, and it can take a week or two before the test results are
available. There are also rapid HIV tests available that can give results in as little as 20 minutes. A positive HIV test result
means that a person may have been infected with HIV. All positive HIV test results, regardless of whether they are from
rapid or conventional tests, must be verified by a second “confirmatory” HIV test.

How can HIV be prevented?

Because the most common ways HIV is transmitted is through anal or vaginal sex or sharing drug injection equipment
with a person infected with HIV, it is important to take steps to reduce the risks associated with these. They include:

• Know your HIV status. Everyone between the ages of 13 and 64 should be tested for HIV at least once. If you are
at increased risk for HIV, you should be tested for HIV at least once a year.

 If you have HIV, you can get medical care, treatment, and supportive services to help you stay healthy and
reduce your ability to transmit the virus to others.
 If you are pregnant and find that you have HIV, treatments are available to reduce the chance that your baby
will have HIV.

• Abstain from sexual activity or be in a long-term mutually monogamous relationship with an uninfected partner.

• Limit your number of sex partners. The fewer partners you have, the less likely you are to encounter someone
who is infected with HIV or another STD.
• Correct and consistent condom use. Latex condoms are highly effective at preventing transmission of HIV and
some other sexually transmitted diseases. “Natural” or lambskin condoms do not provide sufficient protection against
HIV infection.

• Get tested and treated for STDs and insist that your partners do too.

• Male circumcision has also been shown to reduce the risk of HIV transmission from women to men during
vaginal sex.

• Do not inject drugs. If you inject drugs, you should get counseling and treatment to stop or reduce your drug
use. If you cannot stop injecting drugs, use clean needles and works when injecting.

• Obtain medical treatment immediately if you think you were exposed to HIV. Sometimes, HIV medications can
prevent infection if they are started quickly. This is called post-exposure prophylaxis.

• Participate in risk reduction programs. Programs exist to help people make healthy decisions, such as
negotiating condom use or discussing HIV status. Your health department can refer you to programs in your area.

GENERAL PRE-TEST AND POST-TEST INFORMATION

Counseling before and after an HIV test is important because it provides critical information about HIV itself and about
the testing process. While counseling services may not be available in all health care settings, many testing sites do offer
these services. If you would like access to pre-test and post-test counseling, be sure to inquire about the availability of
these services at your chosen test site. If they do not have them readily available, the staff may be able to direct you to
alternate service providers who do.

Pre-test counseling sessions generally include the following:

• Information about the HIV test—what it tests for, what it might NOT tell you, and how long it will take you to get
your results

• Information about how HIV is transmitted and how you can protect yourself from infection

• Information about the confidentiality of your test results

• A clear, easy-to-understand explanation of what your test results mean

Once the results are available, you will usually be given the results in private and in person. Post-test counseling
generally includes:

• Clear communication about what your test result means

• HIV prevention counseling, if your results are negative

• A confirmatory test, called a Western blot test, if your results are positive. The results of that test should be
available within 2 weeks.

IF YOUR HIV TEST IS POSITIVE

• Your counselor will discuss what it means to live a healthy life with HIV and how you can keep from infecting
others.

• Your counselor will also talk about treatments for HIV and can link you to a physician for immediate care.
Getting into treatment quickly is important—it can help you keep your immune system healthy and keep you from
progressing to AIDS.
• All HIV-positive test results must be reported to your state health department for data tracking. Many states
then report data to the CDC, but no personal information (name, address, etc.) is ever shared when those data are
reported.

HIV PRE-TEST AND POST TEST COUNSELING FOR PREGNANT WOMEN

CDC has outlined these recommendations for HIV counseling and testing of pregnant women:

• All pregnant women should be tested for HIV as early as possible during pregnancy, and HIV screening should be
included in the routine panel of prenatal screening tests.

• Patients should be informed that HIV screening is recommended for all pregnant women and that it will be
performed unless they decline (opt-out screening).

• If a pregnant woman declines to be tested for HIV, her healthcare providers should explore and address her
reasons for declining HIV testing.

• Pregnant women should receive appropriate health education, including information about HIV and its
transmission, as a routine part of prenatal care.

• Access to clinical care, prevention counseling, and support services is essential for women with positive HIV test
results.

• HIV screening should be repeated in the third trimester of pregnancy for women known to be at high risk for
HIV.

• Repeat HIV testing in the third trimester is also recommended for all women in areas with higher rates of HIV or
AIDS and for women receiving healthcare in facilities with at least one diagnosed HIV case per 1,000 pregnant women
per year.
 Non-communicable disease

A non-communicable disease, or NCD, is a medical condition or disease which by definition is non-infectious and non-
transmissible among people. NCDs may be chronic diseases of long duration and slow progression, or they may result in
more rapid death such as some types of sudden stroke. They include autoimmune diseases, heart disease, stroke, many
cancers, asthma,diabetes, chronic kidney disease, osteoporosis, Alzheimer's disease, cataracts, and more. While
sometimes (incorrectly) referred to as synonymous with "chronic diseases", NCDs are distinguished only by their non-
infectious cause, not necessarily by their duration. Some chronic diseases of long duration, such as HIV/AIDS, are caused
by transmissible infections. Chronic diseases require chronic care management as do all diseases that are slow to
develop and of long duration.

The World Health Organization (WHO) reports NCDs to be by far the leading cause of mortality in the world,
representing over 60% of all deaths. Out of the 36 million people who died from NCDs in 2005, half were under age 70
and half were women.[1] Of the 57 million global deaths in 2008, 36 million were due to NCDs.That is approximately
63% of total deaths worldwide. Risk factors such as a person's background, lifestyle and environment are known to
increase the likelihood of certain NCDs. Every year, at least 5 million people die because of tobacco use and about 2.8
million die from being overweight. High cholesterol accounts for roughly 2.6 million deaths and 7.5 million die because
of high blood pressure. By 2030, deaths due to chronic NCDs are expected to increase to 52 million per year while
deaths caused by infectious diseases, maternal and perinatal conditions and nutritional deficiencies are expected to
decline by 7 million per year during the same period.

Causes and risk factors

Risk factors such as a person's background; lifestyle and environment are known to increase the likelihood of certain
non-communicable diseases. They include age, gender, genetics, exposure to air pollution, and behaviours such

The WHO's World Health Report 2002 identified five important risk factors for non-communicable disease in the top ten
leading risks to health. These are raised blood pressure, raised cholesterol, tobacco use, alcohol consumption, and
overweight.[5] Other factors associated with higher risk of NCDs include a person's economic and social conditions, also
known as the "social determinants of health."

It has been estimated that if the primary risk factors were eliminated, 80% of the cases of heart disease, stroke and type
2 diabetesand 40% of cancers could be prevented. Interventions targeting the main risk factors could have a significant
impact on reducing the burden of disease worldwide. Efforts focused on better diet and increased physical activity have
been shown to control the prevalence of NCDs.[3]

"Environmental diseases" NCDs include many environmental diseases, covering a broad category of avoidable and
unavoidable human health conditions caused by external factors, such as sunlight, nutrition, pollution, and lifestyle
choices. The diseases of affluence are non-infectious diseases with environmental causes. Examples include:

• Many types of cardiovascular disease (CVD) • Lower back pain caused by too little exercise

• Chronic obstructive pulmonary disease (COPD) • Malnutrition caused by too little food,or eating
caused by smoking tobacco the wrong kinds of food(e.g. scurvy from lack of Vitamin
C)
• Diabetes mellitus type 2
• Skin cancer caused by radiation from the sun
Inherited diseases

Genetic disorders are caused by errors in genetic information that produce diseases in the affected people. The origin of
these genetic errors can be:

• Spontaneous errors or mutations to the • A change in chromosome numbers, such as

genome: Down syndrome.
• A defect in a gene caused by mutation, such as • An increase in the amount of genetic
Cystic fibrosis. information, such as Chimerism or Heterochromia.

Cystic fibrosis is an example of an inherited disease that is caused by a mutation on a gene. The faulty gene impairs the
normal movement of sodium chloride in and out of cells, which causes the mucus-secreting organs to produce
abnormally thick mucus. The gene is recessive, meaning that a person must have two copies of the faulty gene for them
to develop the disease. Cystic fibrosis affects the respiratory, digestive and reproductive systems, as well as the sweat
glands. The mucus secreted is very thick and blocks passageways in the lungs and digestive tracts. This mucus causes
problems with breathing and with the digestion and absorption of nutrients.

• Inherited genetic errors from parents:

 Dominant genetic diseases, such as Huntingtons, require the inheritance of one erroneous gene to be
expressed.
 Recessive genetic diseases, such as Tay–Sachs, require the inheritance of two erroneous genes to be
expressed.

NCDs and global health

Referred to as a “lifestyle” disease, because the majority of these diseases are preventable illnesses, the most common
causes for non-communicable diseases (NCD) include tobacco use (smoking), alcohol abuse, poor diets (high
consumption of sugar, salt, saturated fats, and trans fatty acids) and physical inactivity. Currently, NCD kills 36 million
people a year, a number that by some estimates is expected to rise by 17–24% within the next decade.

Historically, many NCDs were associated with economic development and were so-called a "diseases of the
rich".However, with an estimated 80% of the four main types of NCDs — cardiovascular diseases, cancers, chronic
respiratory diseases and diabetes — now occurring in low- and middle-income countries,and with two-thirds of people
who are affected by diabetes now residing in developing nations, NCD can no longer be considered just a problem
affecting affluent societies.[9][10] As previously stated, in 2008 alone, NCD's were the cause of 63% of deaths
worldwide; a number that is expected to rise considerably in the near future if measures are not taken.

If present growth trends are maintained, by 2020, NCDs will attribute to 7 out of every 10 deaths in developing
countries, killing 52 million people annually worldwide by 2030.[10] With statistics such as these, it comes as no surprise
that international entities such as the World Health Organization & World Bank Human Development Network have
identified the prevention and control of NCDs as an increasingly important discussion item on the global health agenda.

Thus, should policy makers and communities mobilize “and make prevention and targeted treatment of such diseases a
priority,” sustainable measures can be implemented to stagnate (and eventually even reverse) this emerging global
health threat. Potential measures currently being discussed by the World Health Organization-Food and Agriculture
Organization includes reducing the levels of salt in foods, limiting inappropriate marketing of unhealthy foods and non-
alcoholic beverages to children, imposing controls on harmful alcohol use, raising taxes on tobacco, and curbing
legislation to curb smoking in public places.

NCDs and the United Nations

The World Health Organization is the specialized agency of the United Nations (UN) that acts as coordinating authority
on internationalpublic health issues, including NCDs. In May 2008, the 193 Member States of the WHO approved a six-
year plan to address non-communicable diseases, especially the rapidly increasing burden in low- and middle-income
countries.The plan calls for raising the priority given to NCDs in international development work.

During the 64th session of the United Nations General Assembly in 2010, a resolution was passed to call for a high-level
meeting of the General Assembly on the prevention and treatment NCDs with the participation of heads of state and
government. The resolution also encouraged UN Member States to address the issue of non-communicable diseases at
the 2010 Review Summit for the Millennium Development Goals.
In September 2011, the UN is hosting its first General Assembly Special Summit on the issue of NCDs. Noting that NCDs
are the cause of some 35 million deaths each year, the international community is being increasingly called to take
important measures for the prevention and control of non-communicable diseases, and mitigate their impacts on the
world population especially on women, who are usually the primary caregivers.

Global Non-communicable Disease Network

In order to better coordinate efforts around the globe, in 2009 the WHO announced the launch of the Global Non-
communicable Disease Network (NCDnet).NCDnet will consist of leading health organizations and experts from around
the world in order to fight against diseases such as cancer, cardiovascular disease, and diabetes. Ala Alwan, assistant
director-general for Non-communicable Diseases and Mental Health at the WHO, said: "integrating the prevention of
non-communicable diseases and injuries into the national and global development agendas is not only achievable but
also a priority for developing countries."

NCD Alliance

The NCD Alliance is a global partnership founded in May 2009 by four international federations representing
cardiovascular disease,diabetes, cancer, and chronic respiratory disease. The NCD Alliance brings together roughly 900
national member associations to fight non-communicable disease. Long term aims of the Alliance include:

1. NCD/disease national plans for all 4. Strengthened health systems

2. A tobacco free world 5. Global access to affordable and good quality

medicines and technologies
3. Improved lifestyles
6. Human rights for people with NCDs.
Economics of NCDs

Previously, chronic NCDs were considered a problem limited mostly to high income countries, while infectious diseases
seemed to affect low income countries. The burden of disease attributed to NCDs has been estimated at 85% in
industrialized nations, 70% in middle income nations, and nearly 50% in countries with the lowest national incomes.[3]
In 2008, chronic NCDs accounted for more than 60% (over 35 million) of the 57 million deaths worldwide. Given the
global population distribution, almost 80% of deaths due to chronic NCDs worldwide now occur in low and middle
income countries, while only 20% occur in higher income countries.

National economies are reportedly suffering significant losses because of premature deaths or inability to work resulting
from heart disease, stroke and diabetes. For instance, China is expected to lose roughly $558 billion in national income
between 2005 and 2015 due to early deaths. In 2005, heart disease, stroke and diabetes caused an estimated loss in
international dollars of national income of 9 billion in India and 3 billion in Brazil.

Absenteeism and presenteeism

The burden of chronic NCDs including mental health conditions is felt in workplaces around the world, notably due to
elevated levels ofabsenteeism, or absence from work because of illness, and presenteeism, or productivity lost from
staff coming to work and performing below normal standards due to poor health. For example, the United Kingdom
experienced a loss of about 175 million days in 2006 to absence from illness among a working population of 37.7 million
people. The estimated cost of absences due to illness was over 20 billion pounds in the same year. The cost due to
presenteeism is likely even larger, although methods of analyzing the economic impacts of presenteeism are still being
developed. Methods for analyzing the distinct workplace impacts of NCDs versus other types of health conditions are
also still being developed.

Cancer

For the vast majority of cancers, risk factors are environmental or lifestyle-related, thus cancers are mostly preventable
NCD.Greater than 30% of cancer is preventable via avoiding risk factors including: tobacco, being overweight or obesity,
low fruit and vegetable intake, physical inactivity, alcohol, sexually transmitted infections, and air pollution. Infectious
agents are responsible for some cancers, for instance almost all cervical cancers are caused by human papillomavirus
infection.

Cardiovascular disease

The first studies on cardiovascular health were performed in 1949 by Jerry Morris using occupational health data and
were published in 1958.[20] The causes, prevention, and/or treatment of all forms of cardiovascular disease remain
active fields of biomedical research, with hundreds of scientific studies being published on a weekly basis. A trend has
emerged, particularly in the early 2000s, in which numerous studies have revealed a link between fast food and an
increase in heart disease. These studies include those conducted by the Ryan Mackey Memorial Research Institute,
Harvard University and the Sydney Center for Cardiovascular Health. Many major fast food chains, particularly
McDonald's, have protested the methods used in these studies and have responded with healthier menu options.

A fairly recent emphasis is on the link between low-grade inflammation that hallmarks atherosclerosis and its possible
interventions. C-reactive protein (CRP) is a common inflammatory marker that has been found to be present in
increased levels in patients at risk for cardiovascular disease. Also osteoprotegerin which involved with regulation of a
key inflammatory transcription factor called NF-κBhas been found to be a risk factor of cardiovascular disease and
mortality.

Diabetes

Type 2 Diabetes Mellitus is an NCD which is largely preventable and manageable but difficult to cure. Management
concentrates on keeping blood sugar levels as close to normal ("euglycemia") as possible without presenting undue
patient danger. This can usually be with close dietary management, exercise, and use of appropriate medications (insulin
only in the case of type 1 diabetes mellitus. Oral medications may be used in the case of type 2 diabetes, as well as
insulin).

Patient education, understanding, and participation is vital since the complications of diabetes are far less common and
less severe in people who have well-managed blood sugar levels.[24][25] Wider health problems may accelerate the
deleterious effects of diabetes. These include smoking, elevated cholesterol levels, obesity, high blood pressure, and
lack of regular exercise.

Chronic kidney disease

Although chronic kidney disease (CKD) is not currently identified as one of WHO's main targets for global NCD control,
there is compelling evidence that CKD is not only common, harmful and treatable but also a major contributing factor to
the incidence and outcomes of at least three of the diseases targeted by WHO (diabetes, hypertension and CVD).[26]
CKD strongly predisposes to hypertension and CVD; diabetes, hypertension and CVD are all major causes of CKD; and
major risk factors for diabetes, hypertension and CVD (such as obesity and smoking) also cause or exacerbate CKD. In
addition, among people with diabetes, hypertension, or CVD, the subset who also have CKD are at highest risk of
adverse outcomes and high health care costs. Thus, CKD, diabetes and cardiovascular disease are closely associated
conditions that often coexist; share common risk factors and treatments; and would benefit from a coordinated global
approach to prevention and control.
 Infectious disease

Infectious diseases, also known as transmissible diseases or communicable diseases comprise clinically evident illness
(i.e., characteristic medical signs and/orsymptoms of disease) resulting from the infection, presence and growth of
pathogenicbiological agents in an individual host organism. In certain cases, infectious diseases may be asymptomatic
for much or even all of their course in a given host. In the latter case, the disease may only be defined as a "disease"
(which by definition means an illness) in hosts who secondarily become ill after contact with an asymptomatic carrier.
An infection is notsynonymous with an infectious disease, as some infections do not cause illness in a host.

Infectious pathogens include some viruses, bacteria, fungi, protozoa, multicellularparasites, and aberrant proteins
known as prions. These pathogens are the cause of disease epidemics, in the sense that without the pathogen, no
infectious epidemic occurs.

The term infectivity describes the ability of an organism to enter, survive and multiply in the host, while the
infectiousness of a disease indicates the comparative ease with which the disease is transmitted to other hosts.[2]
Transmission of pathogen can occur in various ways including physical contact, contaminated food, body fluids, objects,
airborne inhalation, or through vector organisms.

Infectious diseases are sometimes called "contagious" when they are easily transmitted by contact with an ill person or
their secretions (e.g., influenza). Thus, a contagious disease is a subset of infectious disease that is especially infective or
easily transmitted. Other types of infectious/transmissible/communicable diseases with more specialized routes of
infection, such as vector transmission or sexual transmission, are usually not regarded as "contagious," and often do not
require medical isolation (sometimes loosely called quarantine) of victims. However, this specialized connotation of the
word "contagious" and "contagious disease" (easy transmissibility) is not always respected in popular use.

ENDEMIC VS PANDEMIC

Endemic: Present in a community at all times but in relatively low frequency. Something that is endemic is typically
restricted or peculiar to a locality or region.

For example, malaria is endemic in some areas of Africa. And traffic in illicit drugs is endemic in some neighborhoods.

By contrast, there are the related terms "epidemic" and "pandemic":

• An epidemic is a sudden severe outbreak within a region or a group, as with AIDS in Africa or AIDS in
intravenous drug users.

• A pandemic occurs when an epidemic becomes very widespread and affects a whole region, a continent, or the
entire world.

The word "endemic" comes from the Greek "en-", "in" + "demos", "people or population" = "endemos" = "in the
population." An endemic is in the people.

By contrast, "epi-" means "upon." An epidemic is visited upon the people. And "pan-" means "all." A pandemic affects all
the people.

DIARRHEA

Diarrhea (AmE) (or diarrhoea) (BrE) (from the Greek διάρροια, δια dia "through" + ρέωrheo "flow" meaning "flowing
through") is the condition of having three or more loose or liquid bowel movements per day.[3] It is a common cause of
death in developing countriesand the second most common cause of infant deaths worldwide. The loss of fluids through
diarrhea can cause dehydration and electrolyte disturbances such as potassium deficiency or other salt imbalances.
Diarrhea is defined by the World Health Organization as having three or more loose or liquid stools per day, or as having
more stools than is normal for that person.

Secretory

Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is
little to no structural damage. The most common cause of this type of diarrhea is a cholera toxin that stimulates the
secretion of anions, especiallychloride ions. Therefore, to maintain a charge balance in the lumen, sodium is carried with
it, along with water. In this type of diarrhea intestinal fluid secretion is isotonic with plasma even during fasting.It
continues even when there is no oral food intake.

Osmotic

Osmotic diarrhea occurs when too much water is drawn into the bowels. If a person drinks solutions with excessive
sugar or excessive salt, these can draw water from the body into the bowel and cause osmotic diarrhea.[6] Osmotic
diarrhea can also be the result of maldigestion (e.g., pancreatic disease or Coeliac disease), in which the nutrients are
left in the lumen to pull in water. Or it can be caused by osmotic laxatives (which work to alleviateconstipation by
drawing water into the bowels). In healthy individuals, too much magnesiumor vitamin C or undigested lactose can
produce osmotic diarrhea and distention of the bowel. A person who has lactose intolerance can have difficulty
absorbing lactose after an extraordinarily high intake of dairy products. In persons who have fructose malabsorption,
excess fructose intake can also cause diarrhea. High-fructose foods that also have a high glucose content are more
absorbable and less likely to cause diarrhea. Sugar alcohols such as sorbitol (often found in sugar-free foods) are difficult
for the body to absorb and, in large amounts, may lead to osmotic diarrhea. In most of these cases, osmotic diarrhea
stops when offending agent (e.g. milk, sorbitol) is stopped.

Exudative

Exudative diarrhea occurs with the presence of blood and pus in the stool. This occurs with inflammatory bowel
diseases, such asCrohn's disease or ulcerative colitis, and other severe infections such as E. coli or other forms of food
poisoning.

Motility-related

Motility-related diarrhea is caused by the rapid movement of food through the intestines (hypermotility). If the food
moves too quickly through the gastrointestinal tract, there is not enough time for sufficient nutrients and water to be
absorbed. This can be due to avagotomy or diabetic neuropathy, or a complication of menstruation[citation needed].
Hyperthyroidism can produce hypermotility and lead to pseudodiarrhea and occasionally real diarrhea. Diarrhea can be
treated with antimotility agents (such as loperamide). Hypermotility can be observed in people who have had portions
of their bowel removed, allowing less total time for absorption of nutrients.

Inflammatory

Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss
of protein-rich fluids and a decreased ability to absorb these lost fluids. Features of all three of the other types of
diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic
infections, or autoimmune problems such as inflammatory bowel diseases. It can also be caused by tuberculosis, colon
cancer, and enteritis.[citation needed]

Dysentery

Generally, if there is blood visible in the stools, it is not diarrhea, but dysentery. The blood is trace of an invasion of
bowel tissue. Dysentery is a symptom of, among others, Shigella, Entamoeba histolytica, and Salmonella.

DIFFERENTIAL DIAGNOSIS
Diarrhea is most commonly due to viral gastroenteritis with rotavirus, which accounts for 40% of cases in children under
five. (p. 17) In travelers however bacterial infectionspredominate. Various toxins such as mushroom poisoning and drugs
can also cause acute diarrhea.

Chronic diarrhea can be the part of the presentations of a number of chronic medical conditions affecting the intestine.
Common causes include ulcerative colitis, Crohn's disease, microscopic colitis, celiac disease, irritable bowel syndrome
and bile acid malabsorption.

Infections

There are many causes of infectious diarrhea, which include viruses, bacteria and parasites. Norovirus is the most
common cause of viral diarrhea in adults, but rotavirusis the most common cause in children under five years
old.Adenovirus types 40 and 41, and astroviruses cause a significant number of infections.

The bacterium Campylobacter is a common cause of bacterial diarrhea, but infections by Salmonellae, Shigellae and
some strains ofEscherichia coli (E.coli) are frequent.

In the elderly, particularly those who have been treated with antibiotics for unrelated infections, a toxin produced by
Clostridium difficileoften causes severe diarrhea.

Parasites do not often cause diarrhea except for the protozoan Giardia, which can cause chronic infections if these are
not diagnosed and treated with drugs such as metronidazole, and Entamoeba histolytica.

Other infectious agents such as parasites and bacterial toxins also occur. In sanitary living conditions where there is
ample food and a supply of clean water, an otherwise healthy person usually recovers from viral infections in a few days.
However, for ill or malnourishedindividuals, diarrhea can lead to severe dehydration and can become life-threatening.

Malabsorption

Malabsorption is the inability to absorb food fully, mostly from disorders in the small bowel, but also due to
maldigestion from diseases of the pancreas.

Causes include:

• enzyme deficiencies or mucosal abnormality, as in food allergy and food intolerance, e.g. celiac disease (gluten
intolerance),lactose intolerance (intolerance to milk sugar, common in non-Europeans), and fructose malabsorption.

• pernicious anemia, or impaired bowel function due to the inability to absorb vitamin B12,

• loss of pancreatic secretions, which may be due to cystic fibrosis or pancreatitis,

• structural defects, like short bowel syndrome (surgically removed bowel) and radiation fibrosis, such as usually
follows cancer treatment and other drugs, including agents used in chemotherapy; and

• certain drugs, like orlistat, which inhibits the absorption of fat.

Inflammatory bowel disease

The two overlapping types here are of unknown origin:

• Ulcerative colitis is marked by chronic bloody diarrhea and inflammation mostly affects the distal colon near the
rectum.

• Crohn's disease typically affects fairly well demarcated segments of bowel in the colon and often affects the end
of the small bowel.

Irritable bowel syndrome

Another possible cause of diarrhea is irritable bowel syndrome (IBS) which usually presents with abdominal discomfort
relieved by defecation and unusual stool (diarrhea or constipation) for at least 3 days a week over the previous 3
months.[19] Symptoms of diarrhea-predominant IBS can be managed through a combination of dietary changes, soluble
fiber supplements, and/or medications such asloperamide or codeine. About 30% of patients with diarrhea-predominant
IBS have bile acid malabsorption diagnosed with an abnormalSeHCAT test.[20]

Other causes

• Diarrhea can be caused by chronic ethanol ingestion.

• Ischemic bowel disease. This usually affects older people and can be due to blocked arteries.

• Microscopic colitis, a type of inflammatory bowel disease where changes are only seen on histological
examination of colonic biopsies.

• Bile salt malabsorption (primary bile acid diarrhea) where excessive bile acids in the colon produce a secretory
diarrhea.

• Hormone-secreting tumors: some hormones (e.g., serotonin) can cause diarrhea if excreted in excess (usually
from a tumor).

• Chronic mild diarrhea in infants and toddlers may occur with no obvious cause and with no other ill effects; this
condition is calledtoddler's diarrhea.
 Dehydration and diarrhea in children: Prevention and treatment

What are the symptoms of dehydration?

Dehydration is caused by a loss of body fluids, which are made up of water and salts. When sick children have diarrhea
or are vomiting, they can lose large amounts of salts and water from their bodies and can become dehydrated very
quickly.

Dehydration can be very dangerous, especially for babies and toddlers. Children can even die if they are not treated.

What are the signs of dehydration?

Call your child’s doctor or seek medical advice if you see signs of dehydration:

• decreased urination (fewer than 4 wet diapers • faster heart beat,

in 24 h),
• sunken eyes,
• increased thirst,
• grayish skin,
• no tears,
• sunken soft spot (fontanelle) on baby’s head.
• dry skin, mouth and tongue,
Healthy children can spit up, vomit or have a loose stool once in a while without being in danger of dehydrating.

What are the symptoms of diarrhea?

Diarrhea is a very common problem in babies and children. It is usually mild and brief. ”Acute” diarrhea lasts less than 1
week.

A child has diarrhea if she has more bowel movements than usual, and if stools are less formed and more watery than
usual. Sometimes children with diarrhea have other symptoms, such as fever, loss of appetite, nausea, vomiting,
stomach pains, cramps, and blood and/or mucus in the bowel movement.

Diarrhea can be dangerous if not treated properly because it drains water and salts from your child. If these fluids are
not put back quickly, your child may become dehydrated and may need to be hospitalized.

How diarrhea spreads?

Diarrhea germs are easily spread from person to person, and especially from child to child. They usually spread quickly
among children who have not learned to use the toilet.

What causes diarrhea?

There are many different possible causes of diarrhea. The most common are:

• Viruses, such as rotavirus, which can’t be treated with antibiotics.

• Bacteria, such as Campylobacter, Salmonella, Shigella and E. coli. Some bacterial diarrhea can be treated with
antibiotics, but children usually start to get better before the bacteria are identified.

• Food poisoning.

• Parasites, such as giardia.

Rotavirus

Rotavirus is the most common cause of acute diarrhea in babies and young children. It usually affects children between
the ages of 6 months and 2 years.
Rotavirus illness starts between 12 hours and 4 days after being exposed to the germ. The first signs are usually a high
fever (40ºC/104ºF) and vomiting. Within 12 to 24 hours, children start to pass large amounts of watery diarrhea. The
illness usually lasts 3 to 7 days.

When children have rotavirus, their stools contain large numbers of germs. Rotavirus can spread directly (such as by
coming in contact with an infected diaper and not washing hands properly afterward), or indirectly (for example, coming
in contact with a toy that has germs on it).

Outbreaks of rotavirus in Canada usually happen in the winter and spring, between December and May. A vaccine to
prevent rotavirus is available in Canada.

How to prevent diarrhea

Proper handwashing and safe food handling are the most important ways to prevent the spread of germs that cause
diarrhea.

How to treat diarrhea

Children with diarrhea need to keep drinking the right amount of fluids to avoid dehydration.

Oral rehydration solutions

An oral rehydration solution (ORS) is an exact mixture of water, salts and sugar. These solutions can be absorbed even
when your child is vomiting. The key is to give small amounts of ORS often (for example, 1 teaspoon every 5 minutes),
gradually increasing the amount until your child can drink normally.

Oral rehydration solutions are available at pharmacies in ready-to-serve preparations, frozen popsicles and powders.

Although powders are cheaper and easier to store, they have to be mixed very carefully to work properly. It is better to
buy an ORS that has already been mixed.

Oral rehydration solutions can be used to:

• keep children well hydrated when their diarrhea is serious.

• put back fluids when children show signs of mild dehydration.

If you are breastfeeding, keep feeding on demand. You can also offer your child the foods he usually eats.

If you are formula feeding, you don’t need to dilute the formula. Continue formula feeding, and offer your child the
food he normally eats.

If your child is not breastfeeding or formula feeding well, offer ORS as follows:

For the first 4 hours

• For babies 6 months and younger: give 30 to 90 mL (1 to 3 oz.) every hour.

• At 6 to 24 months: give 90 to 125 mL (3 to 4 oz.) every hour.

• Children over 2 years of age: give 125 to 250 mL (4 to 8 oz.) every hour.

• If an infant refuses the ORS by the cup or bottle, give the solution using a medicine dropper, small teaspoon or
frozen popsicles.

• If a child vomits, you may need to stop giving food and drink. But continue to give the ORS using a spoon. Give
15 mL (1 tbsp.) every 10 min to 15 min until the vomiting stops. Increase the amounts gradually until your child is able to
drink the regular amounts. If vomiting does not stop after 4 to 6 hours, take your child to the hospital.
After 4 hours until 24 hours: Recovery stage

• Keep giving your child the oral rehydration solution until diarrhea is less frequent.

• When vomiting decreases (and depending on your child’s age), it is important to start your child breastfeeding
as usual (or drinking formula or whole milk) or eating regular food in small, frequent feedings.

After 24 to 48 hours, most children can resume their normal diet.

Stools may increase at first (1 or 2 more each day). It may take 7 to 10 days or longer for stools to become completely
formed. This is part of normal healing in a child’s bowel system (intestine).

Foods to avoid

Do not give your child sugary drinks such as: fruit juice or sweetened fruit drinks, carbonated drinks (pop/soda),
sweetened tea, broth or rice water. These have the wrong amounts of water, salts and sugar and can make your child’s
diarrhea worse.

If your child is having frequent diarrhea, do not offer plain water. Drinking only water may lead to low blood sugar or
low sodium levels in your child’s blood.

Talk to your doctor before giving over-the-counter medications to stop diarrhea.

When to call the doctor?

• Your child has diarrhea and is less than 6 • Your child has signs of dehydration (as listed
months of age. above)

• Your child has bloody or black stools. • Your child has stomach pains that are getting
worse.
• Your child is still vomiting after 4 to 6 hours.

• Your child has diarrhea and a fever with a

temperature higher than 38.5°C (101.5°F).
Diarrhea lasting for more than 1 to 2 weeks is considered chronic. Talk to your child’s doctor if this is the case.
 Myocardial Infarction (Heart Attack)

A heart attack (myocardial infarction) is usually caused by a blood clot, which stops the blood flowing to a part of your
heart muscle. You should call for an ambulance immediately if you develop severe chest pain. Treatment with a clot-
busting medicine or an emergency procedure to restore the blood flow through the blocked blood vessel are usually
done as soon as possible. This is to prevent or minimise any damage to your heart muscle. Other treatments help to
ease the pain and to prevent complications. Reducing various risk factors can help to prevent a myocardial infarction.

Understanding the heart and coronary arteries

The heart is mainly made of special muscle (myocardium). The heart pumps blood into arteries (blood vessels) which
take the blood to every part of the body. Like any other muscle, the heart muscle needs a good blood supply. The
coronary arteries take blood to the heart muscle. The main coronary arteries branch off from the aorta (the large artery
which takes oxygen-rich blood from the heart chambers to the body.) The main coronary arteries divide into smaller
branches which take blood to all parts of the heart muscle.

What happens to your heart with a myocardial infarction?

If you have a myocardial infarction (heart attack), a coronary artery or one of its smaller branches is suddenly blocked.
The part of the heart muscle supplied by this artery loses its blood (and oxygen) supply if the vessel is blocked. This part
of the heart muscle is at risk of dying unless the blockage is quickly removed. When a part of the heart muscle is
damaged it is said to be infarcted. The term myocardial infarction (MI) means damaged heart muscle.

If a main coronary arteries is blocked, a large part of the heart muscle is affected. If a smaller branch artery is blocked, a
smaller amount of heart muscle is affected. After an MI, if part of the heart muscle has died, it is replaced by scar tissue
over the next few weeks.

Some newer terms used by doctors

A heart attack and myocardial infarction (MI) are commonly used terms, and mean the same thing. However, the term
MI is used less often now by doctors. This is because there are actually a range of conditions that can be caused by a
sudden reduction in blood flow in a coronary artery. This range of conditions has an overall term called acute coronary
syndrome (ACS). Two main sub types of ACS can be diagnosed by what is seen on your heart tracing (ECG). The two main
types are called ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI). NSTEMI can also include unstable angina.
(The ST elevation refers to a section on the ECG tracing.) In STEMI, the artery supplying an area of the heart muscle is
completely blocked. However, in NSTEMI, the artery is only partly blocked, so only part of the heart muscle supplied by
the affected artery is affected. Your treatment can depend upon which type you have - STEMI or NSTEMI.

This article mainly discusses STEMI - which is just referred to as myocardial infarction (MI) from now on. For information
on NSTEMI, unstable angina and ASC in general, see separate leaflet called Acute Coronary Syndrome.

What causes a myocardial infarction?

Blood clot (thrombosis) - the cause in most cases

The most common cause of an MI is a blood clot (thrombosis) that forms inside a coronary artery, or one of its
branches. This blocks the blood flow to a part of the heart.

Blood clots do not usually form in normal arteries. However, a clot may form if there is someatheroma within the lining
of the artery. Atheroma is like fatty patches or plaques that develop within the inside lining of arteries. (This is similar to
water pipes that get furred up.) Plaques of atheroma may gradually form over a number of years in one or more places
in the coronary arteries. Each plaque has an outer firm shell with a soft inner fatty core.

What happens is that a crack develops in the outer shell of the atheroma plaque. This is called plaque rupture. This
exposes the softer inner core of the plaque to blood. This can trigger the clotting mechanism in the blood to form a
blood clot. Therefore, a build-up of atheroma is the root problem that leads to most cases of ACS / MI. (The diagram
below shows four patches of atheroma as an example. However, atheroma may develop in any section of the coronary
arteries.)

Treatment with clot-busting medication or a procedure called angioplasty (see below) can break up the clot and restore
blood flow through the artery. If treatment is given quickly enough this prevents damage to the heart muscle, or limits
the extent of the damage.

Uncommon causes

Various other uncommon conditions can block a coronary artery. For example: inflammation of the coronary arteries
(rare); a stab wound to the heart; a blood clot forming elsewhere in the body (for example, in a heart chamber) and
travelling to a coronary artery where it gets stuck; taking cocaine, which can cause a coronary artery to go into spasm;
complications from heart surgery and some other rare heart problems. These are not dealt with further in this leaflet.

The rest of this leaflet deals only with the common cause - thrombosis over an atheroma plaque.

Who is at risk of having a myocardial infarction / heart attack?

MI is common. About 146,000 people in the UK have an MI every year. Most occur in people aged over 50 and it
becomes more common with increasing age. Sometimes younger people are affected.

MI is three times more common in young men than in young women. However, after the menopause, the female
hormones no longer protect the heart so the risk is then the same for men and women.

MI may occur in people known to have heart disease, such as people with angina. It can also happen out of the blue in
people with no previous symptoms of heart disease. This is because atheroma often develops without any symptoms at
first.

Certain risk factors increase the risk of more atheroma forming. This can lead to ACS / MI. See separate leaflet called
Preventing Cardiovascular Diseases which discusses these in more detail.

Briefly, risk factors that can be modified and may help to prevent MI include:

• Smoking. If you smoke, you should make every effort to stop.

• High blood pressure. If your blood pressure is high it can be treated.

• If you are overweight, losing some weight is advised. Losing weight will reduce the amount of workload on your
heart and also help to lower your blood pressure.

• A high cholesterol. This should usually be treated if it is high.

• Inactivity. You should aim to do some moderate physical activity on most days of the week for at least 30
minutes - for example, brisk walking, swimming, cycling, dancing, gardening, etc.

• Diet. You should aim to eat a healthy diet.

• Diabetes. People with diabetes have a higher risk of having ACS. This risk can be reduced by ensuring your blood
pressure, cholesterol levels and glucose levels are well controlled.

• Family history. Your risk is increased if there is a family history of heart disease or a stroke that occurred in your
father or brother aged below 55, or in your mother or sister aged below 65.

• Ethnic group. Certain ethnic groups - for example, British Asians - have a higher risk of developing cardiovascular
diseases.

What are the symptoms of a myocardial infarction?

The most common symptom is severe chest pain, which often feels like a heavy pressure feeling on your chest. The pain
may also travel up into your jaw and down your left arm or down both arms. You may also sweat, feel sick and feel faint.
You may also feel short of breath. The pain may be similar to angina, but it is usually more severe and lasts longer.
(Angina usually goes off after a few minutes. MI pain usually lasts more than 15 minutes - sometimes several hours.)

However, some people have only a mild discomfort in their chest. The pain can sometimes feel like indigestion or
heartburn.

Occasionally, an MI happens without causing any pain. This is usually diagnosed when you have an electrocardiogram
(ECG, or heart tracing) at a later stage.

Some people collapse and die suddenly, if they have a large portion of heart muscle damaged. This is not very common.

What should I do if I think I am having a myocardial infarction?

Call for an ambulance immediately.

Then, if you have some, take one aspirin tablet (see below for the reason for this). You will normally be admitted straight
to hospital.

How is a myocardial infarction diagnosed and assessed?

Many people develop chest pains that are not due to an MI. For example, you can have quite bad chest pains with
heartburn, gallbladder problems or with pains from conditions of the muscles in the chest wall. Therefore, tests are
usually done to confirm an MI. These are:

• An ECG. There are typical changes to the normal pattern of the heart tracing in MI. Patterns that occur include
things called pathological Q waves and ST elevation. However, it is possible to have a normal ECG even if you have had
an MI.

• Blood tests. A blood test that measures a chemical called troponin is the usual test that confirms MI. This
chemical is present in heart muscle cells. Damage to heart muscle cells releases troponin into the bloodstream. In MI the
blood level of troponin increases within 3-12 hours from the onset of chest pain, peaks at 24-48 hours, and returns to a
normal level over 5-14 days.

A rough idea as to the severity of the MI (the amount of heart muscle that is damaged) can be gauged by the degree of
abnormality of the ECG and the level of troponin in the blood. Another chemical that may be measured in a blood test is
called creatine kinase. This too is released from heart muscle cells during MI.

Your heart tracing will be monitored for a few days to check on the heart rhythm. Various blood tests will be done to
check on your general well-being.

Other tests may be done in some cases. This may be to clarify the diagnosis (if the diagnosis is not certain) or to
diagnose complications such as heart failure if this is suspected. For example, an echocardiogram (an ultrasound scan of
the heart) or a test called myocardial perfusion scintigraphy may be done.

Also, before discharge from hospital, you may be advised to have tests to assess the severity of atheroma in the
coronary arteries. For example, an ECG taken whilst you exercise on a treadmill or bike (exercise tolerance test). An
angiography of the coronary arteries may also be performed. In this test a dye is injected into the coronary arteries. The
dye can be seen by special X-ray equipment. This shows up the structure of the arteries (like a road map) and can show
the location and severity of any atheroma.

What is the treatment for a myocardial infarction?

The following is a typical situation and mentions the common treatments that are usually offered. However, each case is
different and treatments may vary depending on your situation.
Aspirin and other antiplatelet medicines

As soon as possible after MI is suspected you will be given a dose of aspirin. Aspirin reduces the stickiness of platelets.
Platelets are tiny particles in the blood that trigger the blood to clot. It is the platelets that become stuck on to a patch of
atheroma inside an artery that go on to form the clot.

Other antiplatelet medicines called clopidogrel or ticagrelor may be given. They work in a different way to aspirin and
help reduce platelet stickiness.

Injections of heparin or a similar medicine

These are usually given for a few days to help prevent further blood clots from forming.

Pain relief

A strong painkiller such as morphine is given by injection into a vein to ease the pain.

Treatment to restore blood flow in the blocked coronary artery

The part of the heart muscle starved of blood does not die immediately. If blood flow is restored within a few hours,
much of the heart muscle that would have been damaged and die will survive. This is why MI is a medical emergency,
and treatment is given urgently. The quicker the blood flow is restored, the better the outlook.

There are two treatments that can restore blood flow back through the blocked artery:

• Emergency angioplasty. Ideally this is the best treatment if it is available and can be done within a few hours of
symptoms starting. In this procedure a tiny wire with a balloon at the end is put into a large artery in the groin or arm. It
is then passed up to the heart and into the blocked section of a coronary artery, using special X-ray guidance. The
balloon is blown up inside the blocked part of the artery to open it wide again. A stent may be left in the widened
section of the artery. A stent is like a wire mesh tube which gives support to the artery and helps to keep the artery
widened. See separate leaflet called Angioplastyfor details.

• An injection of a clot-busting medicine is an alternative to emergency angioplasty. It can be given easily and
quickly in most situations. Some ambulance crews are trained to give this.Note: a common clot-busting medicine used in
the UK is called streptokinase. If you are given this medicine you should not be given it again if you have another MI in
the future. This is because antibodies develop to it and it will not work so well a second time. An alternative clot-busting
medicine should be given.

Both the above treatments usually work well to restore blood flow and greatly improve the outlook. The most crucial
factor is the speed that one or other treatment is given after symptoms started.

A beta-blocker medicine

Beta-blocker medicines block the action of certain hormones such as adrenaline (epinephrine). These hormones increase
the rate and force of the heartbeat. Beta-blocker medicines have some protective effect on the heart muscle and they
also help to prevent abnormal heart rhythms from developing. Beta-blocker medicines will also help to prevent having
another MI.

Insulin

Some people have a raised blood sugar level when they have an MI, even if they do not have diabetes. If this occurs,
then your blood sugar levels may need to be controlled with insulin. If you have diabetes then it is also likely that you
will need to be treated with insulin to control your blood glucose levels when you are in hospital.

Oxygen

You may be given oxygen which works to reduce the risk of damage to your heart muscle.
Treatment after you have had a myocardial infarction

Normally you will be advised to take regular medication for the rest of your life. See separate leaflet called Medication
After a Myocardial Infarction which discusses this more fully.

Briefly, the following four medicines are commonly prescribed to help prevent a further MI, and to help prevent
complications:

• Aspirin - to reduce the stickiness of platelets in the blood, which helps to prevent blood clots forming. If you are
not able to take aspirin then an alternative antiplatelet medicine such as clopidogrel or ticagrelor may be advised.

• A beta-blocker medicine - to slow the heart rate and to reduce the chance of abnormal heart rhythms
developing.

• An angiotensin-converting enzyme (ACE) inhibitor medicine. ACE inhibitor medicines have a number of actions,
including having a protective effect on the heart.

• A statin medicine to lower the cholesterol level in your blood. This helps to prevent the build-up of atheroma.

Also, you will normally be advised to take the antiplatelet medicine clopidogrel or ticagrelor in addition to aspirin.
However, this is usually only advised for a number of weeks or months, depending on the type and severity of your MI.

Many people recover well from an MI and have no complications. Before discharge from hospital, it is common for a
doctor or nurse to advise you how to reduce any risk factors (see above). This advice aims to reduce your risk of a future
MI as much as possible.

Other medicines or treatments may be needed if you develop complications.

How serious is a myocardial infarction?

This often depends on the amount of heart muscle that is damaged. In many cases, only a small part of the heart muscle
is damaged and then heals as a small patch of scar tissue. The heart can usually function normally with a small patch of
scar tissue. A larger heart attack is more likely to be life-threatening or cause complications.

Even before treatments became available to restore blood flow, many people made a full recovery. With the help of
modern treatment, particularly if you are given treatment within a few hours to restore blood flow, a higher percentage
of people now make a full recovery.

Some possible complications include the following:

• Heart failure. If a large area of the heart muscle is damaged, then the pumping ability of the heart may be
reduced. Less blood than usual is then pumped around the body, especially when extra blood is needed when you

exercise. Symptoms such as breathlessness, tiredness, and swollen ankles may develop. Mild heart failure can often be
treated with medication. Severe heart failure can be serious and even life-threatening.

• Abnormal heart rhythms may occur if the electrical activity of the heart is affected. The main risk of this
happening is within the first few hours after an MI. Sudden, chaotic, fast heartbeats may occur. This is called ventricular
fibrillation and is the common cause of cardiac arrest. This needs immediate treatment with an electrical shock given by
a defibrillator. Otherwise, collapse and sudden death is likely. Other less serious abnormal heart rhythms can also occur
which can often be treated with medicines.

• A further MI may occur sometime in the future. This is more likely if the coronary arteries are badly affected
with atheroma, or further build-up of atheroma continues. If the risk of this is thought to be high then surgery may be
advised to bypass or widen severely narrowed coronary arteries.
The most crucial time is during the first day or so. If no complications arise, and you are well after a couple weeks, then
you have a good chance of making a full recovery. A main objective then is to get back into normal life, and to minimise
the risk of a further MI.

After having a myocardial infarction

When recovering from an MI, it is natural to wonder if there are any dos and don'ts. In the past, well-meaning but bad
advice to "rest and take it easy from now on" caused some people to become over-anxious about their hearts. Some
people gave up their jobs, hobbies, and any activity that caused exertion, for fear of straining the heart.

However, quite the opposite is true for most people who recover from an MI. Regular exercise and getting back to
normal work and life are usually advised. Much can be done to reduce the risk of a further MI.

World Health Organization (WHO)

The World Health Organization (WHO) is a specialized agency of the United Nations(UN) that is concerned with
international public health. It was established on 7 April 1948, with headquarters in Geneva, Switzerland, and is a
member of the United Nations Development Group. Its predecessor, the Health Organization, was an agency of
theLeague of Nations.

The constitution of the World Health Organization had been signed by all 61 countries of the United Nations by 22 July
1946, with the first meeting of the World Health Assemblyfinishing on 24 July 1948. It incorporated the Office
International d'Hygiène Publique and the League of Nations Health Organization. Since its creation, WHO has been
responsible for playing a leading role in the eradication of smallpox. Its current priorities includecommunicable diseases,
in particular, HIV/AIDS, malaria and tuberculosis; the mitigation of the effects of non-communicable diseases; sexual and
reproductive health, development, and aging; nutrition, food security and healthy eating; occupational health;
substance abuse; and drive the development of reporting, publications, and networking. WHO is responsible for the
World Health Report, a leading international publication on health, the worldwide World Health Survey, and World
Health Day (7th-April of every Year).

Its links with the International Atomic Energy Agency and distribution of contraceptionhave both proved controversial,
as have guidelines on healthy eating and the 2009 flu pandemic.
 Triage System at the Emergency Department

Triage is the dynamic process of categorising the patient according to treatment priority.

The Triage Center, located infront of the entrance of the Emergency Department , is manned on a 24 hour basis by well
trained Triage Officers.

All cases arriving at he Emergency Department are triaged and sent to the respective areas/zones based upon the
Zoning Concept.

Triage Criteria :

1. Non Critical Cases.

• All walk-in and stable cases.

2. Semi-Critical Cases.

• All hemodynamically stable cases but are unable to walk.

3. Critical Cases.

• Critically ill cases requiring urgent treatment.

Infectious diseases common in Egypt:

• Food and waterborne diseases - the number • typhoid fever

one cause of illness in travelers
• Insect borne diseases
• travelers' diarrhea
• parasitic diseases
• Escherichia coli diarrhea
• filariasis
• hepatitis A / very common
• leishmaniasis
• hepatitis B
• Rift valley fever / rare
• hepatitis C - highest prevalence in world see
www.hcvegypt.com • amebiasis

• schistosomiasis - found in fresh water including • diptheria - endemic to the region

Nile river • West Nile fever
 FOOT AND MOUTH DISEASES

Foot-and-mouth disease or hoof-and-mouth disease (Aphthae epizooticae) is aninfectious and sometimes fatal viral
disease that affects cloven-hoofed animals, including domestic and wild bovids. The virus causes a high fever for two or
three days, followed byblisters inside the mouth and on the feet that may rupture and cause lameness.

Susceptible animals include cattle, water buffalo, sheep, goats, pigs, antelope, deer, andbison.

The virus responsible for the disease is a picornavirus,

HAND FOOT AND MOUTH DISEASE

Hand, foot and mouth disease (HFMD) is a human syndrome caused by intestinal viruses of the picornaviridae family.
The most common strains causing HFMD arecoxsackie A virus and enterovirus 71 (EV-71).[1]

HFMD usually affects infants and children, and is quite common. It is moderately contagious and is spread through direct
contact with the mucus, saliva, or feces of an infected person. It typically occurs in small epidemics in nursery schools or
kindergartens, usually during the summer and autumn months. The usual incubation period is 3–7 days.

It is less common in adults, but those with immune deficiencies are very susceptible. HFMD is not to be confused with
foot-and-mouth disease (also called hoof-and-mouth disease), which is a separate disease affecting sheep, cattle, and
swine (both are caused by members of the picornaviridae family, but are not trans-communicable between humans and
livestock).

Signs and symptoms

• Fever • Body rash, followed by sores with blisters on

palms of hand, soles of feet, and sometimes on the lips.
• Headache The rash is rarely itchy for children, but can be
extremely itchy for adults [3]
• Fatigue
• Sores or blisters may be present on the
• Malaise
buttocks of small children and infants
• Referred ear pain
• Irritability in infants and toddlers
• Sore throat
• Loss of appetite.
• Painful oral, nasal, or facial lesions, ulcers or
• Diarrhea
blisters
The common incubation period (the time between infection and onset of symptoms) is from three to seven days.

Early symptoms are likely to be fever often followed by a sore throat. Loss of appetite and general malaise may also
occur. Between one and two days after the onset of fever, painful sores (lesions) may appear in the mouth or throat, or
both. A rash may become evident on the hands, feet, mouth, tongue, inside of the cheeks, and occasionally the buttocks
(but generally, the rash on the buttocks will be caused by the diarrhea).

Treatment

There is no specific treatment for hand, foot and mouth disease. Individual symptoms, such as fever and pain from the
sores, may be eased with the use of analgesics. HFMD is a viral disease that has to run its course; many doctors do not
prescribe medicine for this illness. Infection in older children, adolescents, and adults is typically mild and lasts
approximately 1 week, occasionally longer. Fever reducers and luke-warm baths can help bring temperature down.

Only a very small minority of sufferers require hospital admission, mainly as a result of uncommon neurological
complications (encephalitis, meningitis, or acute flaccid paralysis) or pulmonary edema/pulmonary hemorrhage.
 Pneumonia - adults (community acquired)

Pneumonia is a breathing (respiratory) condition in which there is an infection of the lung.

This article covers pneumonia in people who have not recently been in the hospital or another health care facility
(nursing home or rehab facility). This type of pneumonia is called community-acquired pneumonia, or CAP.

Causes

Pneumonia is a common illness that affects millions of people each year in the United States. Germs called bacteria,
viruses, and fungi may cause pneumonia.

Ways you can get pneumonia include:

• Bacteria and viruses living in your nose, sinuses, or mouth may spread to your lungs.

• You may breathe some of these germs directly into your lungs.

• You breathe in (inhale) food, liquids, vomit, or fluids from the mouth into your lungs (aspiration pneumonia)

Pneumonia caused by bacteria tends to be the most serious kind. In adults, bacteria are the most common cause of
pneumonia.

• The most common pneumonia-causing germ in adults is Streptococcus pneumoniae (pneumococcus).

• Atypical pneumonia, often called walking pneumonia, is caused by certain other bacteria.

• Pneumocystis jiroveci pneumonia is sometimes seen in people whose immune system is not working well.

Many other bacteria can also cause pneumonia.

Viruses are also a common cause of pneumonia, especially in infants and young children.

Risk factors that increase your chances of getting pneumonia include:

• Chronic lung disease (COPD, bronchiectasis, cystic fibrosis)

• Cigarette smoking

• Dementia, stroke, brain injury, cerebral palsy, or other brain disorders

• Immune system problem (during cancer treatment or due to HIV/AIDS or organ transplant)

• Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes mellitus

• Recent surgery or trauma

• Surgery to treat cancer of the mouth, throat, or neck

Symptoms

The most common symptoms of pneumonia are:

• Cough • Shaking chills

• Fever, which may be mild or high • Shortness of breath

Other symptoms include:

• Confusion, especially in older people • Excess sweating and clammy skin

• Headache • Sharp or stabbing chest pain that gets worse
when you breathe deeply or cough
• Loss of appetite, low energy, and fatigue
Exams and Tests

If you have pneumonia, you may be working hard to breathe, or breathing fast.

The health care provider will hear crackles or abnormal breath sounds when listening to your chest with a stethoscope.
Other abnormal breathing sounds may also be heard through the stethoscope or by tapping on your chest wall
(percussion).

The health care provider will likely order a chest x-ray if pneumonia is suspected.

You may need other tests, including:

• Arterial blood gases to see if enough oxygen is • Culture of your sputum to look for the bacteria
getting into your blood from the lungs or virus that is causing your symptoms

• CBC to check white blood cell count • Pleural fluid culture if there is fluid in the space
around the lungs
• CT scan of the chest
Less often patients may need:

• Bronchoscopy--a flexible tube with a lighted camera on the end passed down to your lungs

• Thoracentesis--removing fluid from the space between the outside lining of the lungs and the chest wall

Treatment

Your doctor must first decide whether you need to be in the hospital. If you are treated in the hospital, you will receive:

• Fluids and antibiotics in your veins

• Oxygen therapy

• Breathing treatments (possibly)

It is very important that you are started on antibiotics very soon after you are admitted (unless you have viral
pneumonia).

You are more likely to be admitted to the hospital if you:

• Have another serious medical problem • Are older than 65 or a young child

• Have severe symptoms • Have been taking antibiotics at home and are
not getting better
• Are unable to care for yourself at home, or are
unable to eat or drink

However, many people can be treated at home. Your doctor may tell you to take antibiotics. Antibiotics help some
people with pneumonia get better.

• Don't miss any doses. Take the medicine until it • Do NOT take cough medicine or cold medicine
is gone, even if you start to feel better. unless your doctor says it is okay. Coughing helps your
body get rid of mucus from your lungs.
Breathing warm, moist (wet) air helps loosen the sticky mucus that may make you feel like you are choking. These things
may help:
• Place a warm, wet washcloth loosely over your
nose and mouth.
• Fill a humidifier with warm water and breathe
in the warm mist.
• Take a couple of deep breaths two or three
times every hour. Deep breaths will help open up your
lungs.
• Tap your chest gently a few times a day and lie
with your head lower than your chest. This can help
bring up mucus from the lungs.
Drink plenty of liquids (as long as your health care
provider says it is okay):
• Drink water, juice, or weak tea
• Drink at least 6 to 10 cups a day

• Do NOT drink alcohol

Get plenty of rest when you go home. If you have trouble sleeping at night, take naps during the day.

Outlook (Prognosis)

With treatment, most patients will improve within 2 weeks. Elderly or very sick patients may need longer treatment.

Those who may be more likely to have complicated pneumonia include:

• Older adults or very young children • Life-threatening changes in the lungs that
require a breathing machine
• People whose immune system does not work
well • Fluid around the lung (pleural effusion)

• People with other, serious medical problems • Lung abscesses

such as diabetes or cirrhosis of the liver

In rare cases, more severe problems may develop,

including:
Your doctor may want to make sure your chest x-ray becomes normal again after you are treated. However, it may take
many weeks for your x-ray to clear up.

When to Contact a Medical Professional

Call your doctor if you have:

• A cough that brings up bloody or rust-colored • Fast or painful breathing

mucus
• Night sweats or unexplained weight loss
• Breathing (respiratory) symptoms that get
worse • Shortness of breath, shaking chills, or persistent
fevers
• Chest pain that gets worse when you cough or
breathe in • Signs of pneumonia and a weak immune system
(for example such as with HIV or chemotherapy)
Prevention

Wash your hands often, especially after:

• Blowing your nose • Diapering

• Going to the bathroom

Also wash your hands before eating or preparing foods.

Don't smoke. Tobacco damages your lung's ability to ward off infection.
Vaccines may help prevent some types of pneumonia. They are even more important for the elderly and people with
diabetes, asthma, emphysema, HIV, cancer, or other long-term conditions:

• Flu vaccine prevents pneumonia and other problems caused by the influenza virus. It must be given each year to
protect against new virus strains.

• Pneumococcal vaccine (Pneumovax, Prevnar) lowers your chances of getting pneumonia fromStreptococcus
pneumoniae.

If you have cancer or HIV, talk to your doctor about ways to prevent pneumonia and other infections.