ASK YOUR PHARMACIST: Frequently Asked Questions on Rabies

What is rabies?

Rabies is a deadly disease caused by a virus found in the saliva or a rabid animal. It causes inflammation of the brain. According to Communities Against Rabies Exposure (CARE), rabies cases continue to cause at least 55,000 deaths a year.

Rabies is also called as hydrophobia (fear of water or any liquid), exhibited by the inability to swallow (especially liquid) and a sensation of choking when trying to drink, which is due to the paralysis of the oropharyngeal muscles.

Who is most at risk?

People most at risk of rabies live in rural areas of Africa and Asia, where access to healthcare and animal health facilities is limited, stray dogs are more common, and fewer pets are regularly vaccinated against rabies. Children are at the highest risk of dog rabies; about 30% to 60% of the victims of dog bites are children less than 15 years of age, and children often play with animals and are less likely to report bites or scratches.

In areas known for rabies, persons with frequent exposure to animals (e.g. veterinarians or animal health workers, wildlife specialists or researchers) are also at high risk.

How do you get rabies?

The virus is usually transmitted by the bite of an infected animal. The virus can also be transmitted if saliva from an infected animal gets into an open wound or onto a mucous membrane such as the eyes, nose, or mouth. Person-person virus transfer may occur when saliva droplets are dispersed in air or upon biting although this rarely happen. Inhalation of rabies virus has been known to occur, but only in very special circumstances, such as a research laboratory.

How long can the rabies virus survive in the environment?

The rabies virus is fragile under most normal conditions. It is destroyed within a few minutes at temperatures greater than 50°C, and survives no more than a few hours at room temperature. The virus is no longer infectious once the material containing the virus is dry. The rabies virus is also easily killed by most common detergents and disinfectants including household bleach, (1/2 cup per one gallon of water).

What animals get rabies?

Only mammals, including people, can get rabies The most common reservoir in the country are dogs, although it could also infect cats, rodents, bats and other warm-blooded animals (domestic and wild).

How do you know if an animal has rabies?

There are 2 forms of rabies illness seen in animals. One is known as the furious form, and animals with this type of rabies can exhibit symptoms such as agitation and increased aggressiveness early on, followed by depression, paralysis, and eventually death. The other type of rabies is called the dumb form, and these animals are lethargic, depressed, and eventually die. Because many illnesses can cause these types of symptoms, rabies can be difficult to diagnose. You cannot always know if an animal has rabies, but if you observe “a pet animal behaving wild or a wild animal behaving tame”, you should consider rabies as a possible cause, and take appropriate precautions.

There is no test of a live animal that can detect the presence of the rabies virus. In order to determine if an animal has rabies, brain tissue must be examined for the presence of characteristic lesions.

Is there any treatment for rabies?

Rabies could be treated if the signs and symptoms of rabies are not yet seen but it is fatal once the signs of infection appear. The most common cause of death is respiratory paralysis.

What should I do if I think I may have been exposed to rabies?

• Clean the wound immediately with soap and water.
• Seek prompt medical attention from a physician or hospital emergency department. Appropriate wound care, including antibiotics, and the need for a tetanus booster will be determined by your health care provider.
• Report the bite to the local health authorities for appropriate follow-up and determination of the need for Post-exposure prophylaxis (PEP).

If you are bitten by a wild animal:

• Try to contain the animal while taking care to prevent additional bites and exposure to saliva.

• Contact the animal control officer or local police for assistance. In the event the animal is euthanized, care should be taken to avoid damage to the brain, which should be submitted to the local rabies laboratory for testing.
• Human treatment to prevent rabies may be started immediately or delayed until the testing results are known.
• If the animal is not available for testing, the decision to start human treatment will be made by the bite victim and his/her physician based on recommendations by the local health department.

If you are bitten by a dog, cat, or other domestic animal:

• Obtain information about the pet including owner’s name, phone, address, description of the animal, and its vaccination status.

• Biting animals should be ordered observed for 10 days by the local health department to ensure that they are free of rabies. If showing signs of rabies, the animal should be euthanized immediately and tested. If the animal dies during the observation period, it must be submitted for testing.
• Bites from other domestic animals (such as horses, cows, goats, and sheep) will be evaluated by your local health department. The animals can usually be observed for 10 days to rule out the possibility of rabies.

How long does it take for rabies to develop?

In animals, development of symptoms can be from 2 weeks to many months.

In humans, symptoms usually develop after 3 – 8 weeks. In some cases, symptoms have appeared as early as 9 days and as long as 7 years after exposure.

The length of time depends on a number of factors including:

• the severity of the bite
• location of bite
• the amount and the strain of the rabies virus.

What are the signs and symptoms of rabies infection in humans?

After being bitten, the person may be free from symptoms that may last for a period of 10-14 days or even 30-50 days more. If not treated promptly, symptoms of rabies may start after that period or even shorter. The infection evolves in two phases:

Prelude or Prodomal phase

Patient experiences:

• Fever
• Headache
• Weakness or restlessness
• Depression
• Loss of appetite
• Numbness or a tingling sensation at bite site
• Nausea and vomiting
• Muscle stiffness
• Excessive salivation
• Sensitivity to light, sound and change of temperature

Neurological phase

• Episodes of uncontrollable excitement recurring with periods of calmness
• Difficulty and pain breathing and swallowing liquid
• Usually feels thirsty but experiences hydrophobia or fear of water
• Paralysis
• Signs of nervous system disorders like, delirium or hallucinations, hyperactivity, seizures and paralysis

Death usually follows within a week after the appearance of symptoms. Often due to cardiac or respiratory failure.

How can I protect my pets?

Vaccination and animal control programs have helped to prevent rabies in most pets. Let your pets be vaccinated for anti-rabies when they reach at least 3 months of age and yearly thereafter for protection on resistant strains. Provide proper nutrition, exercise and shelter for your pets. Keep them in your own backyard as much as possible so as to prevent contact from stray animals or infected ones. It is recommended that you bring your pet to the veterinary clinic as often as possible for regular consultation. Cats and dogs that spend time outdoors may have more risk of coming into contact with a rabid wild animal, but it is important to also vaccinate pets that stay indoors.

What should I do if my pet has bitten someone?

• Urge the victim to seek medical care immediately.
• Check with your veterinarian to see if your pet’s vaccinations are up-to-date.
• Report the bite to your local health department.
• Report any unusual illness or behavior from your pet to the local health department and veterinarian.

• Don’t let your pet free-roam and don’t give your pet away. The animal must be available for observation.
• After the recommended observation period, have your pet vaccinated for rabies if it is overdue.

What should I do if my pet has been bitten by a potentially rabid animal?

• Call your veterinarian immediately.
• Even if your pet is currently vaccinated against rabies, it will need to be vaccinated again.
• Unvaccinated pets exposed to a rabid animal may need to be euthanized (put to sleep) immediately, or placed in strict isolation for six months and then vaccinated prior to release.

How can rabies be prevented?

• Vaccinate your pets against rabies and keep vaccinations up-to-date.
• Any type of animal for which a licensed vaccine exists should be vaccinated, and these include dogs, cats, ferrets, horses, cows, sheep, and goats.
• Do not feed or touch wild animals.
• Avoid contact with strays or pets other than your own.
• If you think your pet or livestock may have been exposed to a rabid animal, report it to your veterinarian.
• Report unusual behavior in stray or wild animals to municipal animal control.
• Report all animal bites immediately to your local health department.

In humans, rabies can be prevented by reducing your exposure to unvaccinated animals, unfamiliar animals, and wild or exotic animals for which vaccines do not exist. In the case of exposure to a potentially rabid animal, there is a Post Exposure Prophylaxis (PEP) treatment which, when administered appropriately, can prevent the disease in exposed persons. There is no PEP treatment available for animals.

Is there a rabies vaccine for people?

There are rabies vaccines available for use in people. In most cases, they are used as part of the PEP treatment for people exposed to potentially rabid animals. Persons in high-risk occupations such as veterinarians and animal control officers, or some people traveling overseas, may have a pre-exposure series of vaccines in order to induce immunity to the rabies virus. In the case of future exposure to a rabid animal, fewer doses of vaccine are required for PEP.

What is Post-Exposure Prophylaxis (PEP)?

PEP is the treatment given to people exposed to potentially or known rabid animals. Guidelines for PEP have been developed by the Advisory Committee on Immunization Practices (ACIP), and include one dose of rabies immune globulin, and a series of 4 doses of rabies vaccine given over a 14 day period. Rabies immune globulin is made up of antibodies to the rabies virus, and is injected into the site of the bite from the animal. The vaccine is administered in the muscle of the arm.  There has never been a case of rabies in a person who has received PEP administered in accordance with the ACIP recommended guidelines.

Will rabies vaccine make me sick?

 

Rabies vaccine is made from killed rabies virus, and cannot cause rabies. The vaccine is no more painful than any other type of vaccination, and side effects are similar to those seen with other vaccines, and can include pain, redness, itching, and swelling at the site of the vaccination. Localized pain and a fever can sometimes follow a rabies immune globulin injection. Most side effects can be managed with an anti-inflammatory medication such as paracetamol. As with any vaccine, some individuals can experience more serious side effects, and a physician should be consulted if this occurs. If you experience an unusual reaction to any vaccine, ask your health care provider to report it to the Food and Drug Administration.

References:

A.D.A.M., Inc., 2012. Rabies. [online] PubMed Health. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002310/ [Accessed 28 February 2013].

World Health Organization, 2012. Rabies Fact Sheet. [online] Available at: http://www.who.int/mediacentre/factsheets/fs099/en/ [Accessed 28 February 2013].

Health Protection Agency, 2012. Rabies: Frequently Asked Questions. [online] Available at: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Rabies/GeneralInformation/ClassicalRabiesFAQs/ [Accessed 28 February 2013].

ASK YOUR PHARMACIST: Frequently Asked Questions on Tuberculosis

What is TB?

TB, or tuberculosis, is a disease caused by bacteria called Mycobacterium tuberculosis. TB usually affects the lungs, but can affect other parts of the body, such as the lymph nodes (glands), the bones and (rarely) the brain. Infection with the TB germ may not develop into TB disease.

According to the Department of Health, TB is the number six leading cause of death in the country, with 73 Filipinos dying every day of TB.

What are the symptoms?

TB disease develops slowly in the body, and it usually takes several months for symptoms to appear.

Any of the following symptoms may suggest TB:

• Fever and night sweats
• Persistent cough
• Losing weight
• Blood in your sputum (phlegm or spit) at any time

If you are concerned that you might have TB because you develop any of these symptoms, visit your doctor for advice.

How do you catch it?

TB is spread through the air from one person to another. The bacteria are put into the air when a person with TB disease of the lungs or throat coughs or sneezes. People nearby may breathe in these bacteria and become infected.

When a person breathes in TB bacteria, the bacteria can settle in the lungs and begin to grow. From there, they move through the blood to other parts of the body, such as the kidney, spine, and brain.

TB in the lungs or throat can be infectious. This means that the bacteria can be spread to other people. TB in other parts of the body, such as the kidney or spine, is usually not infectious.

People with TB disease are most likely to spread it to people they spend time with every day. This includes family members, friends, and coworkers.

Can anyone get it?

Anyone can get TB. But with a good immune system, it is hard to fully develop the disease. You are most at risk if someone living in the same house as you catches the disease, or a close friend has the disease.

The following people have a greater chance of becoming ill with TB if exposed to it:

• Those in very close contact with infectious people
• Children
• Elderly people
• Diabetics
• People on steroids
• People on other drugs affecting the body’s defense system
• People who are HIV-positive
• People in overcrowded, poor housing
• People who are dependent on drugs or alcohol
• People with chronic poor health

How is TB treated?

There is good news for people with TB disease! TB disease can almost always be cured with medicine. But the medicine must be taken as the doctor or nurse tells you.

The most common drugs used to fight TB are:

• Iisoniazid (INH)
• Rifampin ( RIF)
• Pyrazinamide (PZA)
• Ethambutol (EMB)

If you have TB disease, you will need to take several different drugs. This is because there are many bacteria to be killed. Taking several drugs will do a better job of killing all of the bacteria and preventing them from becoming resistant to the drugs.

If you have TB of the lungs or throat, you are probably infectious. You need to stay home from work or school so that you don’t spread TB bacteria to other people. After taking your medicine for a few weeks, you will feel better and you may no longer be infectious to others. Your doctor or nurse will tell you when you can return to work or school.

Having TB should not stop you from leading a normal life. When you are no longer infectious or feeling sick, you can do the same things you did before you had TB. The medicine that you are taking should not affect your strength, sexual function, or ability to work. If you take your medicine as your doctor or nurse tells you, the medicine will kill all the TB bacteria. This will keep you from becoming sick again.

What Are the Side Effects of Drugs for TB?

Medicine for TB is relatively safe. Occasionally like any drug, these drugs may cause side effects. Some side effects are minor problems. Others are more serious. If you have a serious side effect, call your doctor or nurse immediately. You may be told to stop taking your medicine or to return to the clinic for tests.

The side effects listed below are serious. If you have any of these symptoms, call your doctor or nurse immediately:

• No appetite
• Nausea
• Vomiting
• Yellowish skin or eyes
• Fever for 3 or more days
• Abdominal pain
• Tingling fingers or toes
• Skin rash
• Easy bleeding
• Aching joints
• Dizziness
• Tingling or numbness around the mouth
• Easy bruising
• Blurred or changed vision
• Ringing in the ears

The side effects listed below are less serious problems. If you have any of these side effects, you can continue taking your medicine:

• Rifampin can turn urine, saliva, or tears orange. The doctor or nurse may advise you not to wear soft contact lenses because they may get stained.
• Rifampin can make you more sensitive to the sun. This means you should use a good sunscreen and cover exposed areas so you don’t burn.
• Rifampin also makes birth control pills and implants less effective. Women who take rifampin should use another form of birth control.
• If you are taking rifampin as well as methadone (used to treat drug addiction), you may have withdrawal symptoms. Your doctor or nurse may want to adjust your methadone dosage.

Why Do I Need to Take TB Medicine Regularly?

TB bacteria die very slowly. It takes at least 6 months for the medicine to kill all the TB bacteria. You will probably start feeling well after only a few weeks of treatment. But beware! The TB bacteria are still alive in your body. You must continue to take your medicine until all the TB bacteria are dead, even though you may feel better and have no more symptoms of TB disease.

If you don’t continue taking your medicine after you feel better or you aren’t taking your medicine regularly, this can be very dangerous. The TB bacteria will grow again and you will relapse or remain sick for a longer time. The bacteria may also become resistant to the drugs you are taking. You may need new, different drugs to kill the TB bacteria if the old drugs no longer work. These new drugs must be taken for a longer time and usually have more serious side effects.

If you become infectious again, you could give TB bacteria to your family, friends, or anyone else who spends time with you. It is very important to take your medicine the way your doctor or nurse tells you.

How Can I Remember to Take My Medicine?

The only way to get well is to take your medicine exactly as your doctor or nurse tells you. This will not be easy! You will be taking your medicine for a long time (6 months or longer), so you should get into a routine. Here are some ways to remember to take your medicine:

• Participate in the directly observed therapy (DOT) program at your health department.
• Take your pills at the same time every day — for example, you can take them before eating breakfast, during a coffee break, or after brushing your teeth.
• Ask a family member or a friend to remind you to take your pills.
• Mark off each day on a calendar as your take your medicine.
• Put your pills in a weekly pill dispenser. Keep it by your bed or in your purse or pocket.

NOTE: Remember to keep all medicine out of reach of children.

If you forget to take your pills one day, skip that dose and take the next scheduled dose. Tell your doctor or nurse that you missed a dose. You may also call your doctor or nurse for instructions.

The best way to remember to take your medicine is to get directly observed therapy (DOT). If you get DOT, you will meet with a health care worker every day or several times a week. Usually you will meet at a place you both agree on. This might be the TB clinic, your home or work, or any other convenient location. You will take your medicine at this place.

DOT helps in several ways. The health care worker can help you remember to take your medicine and complete your treatment. This means you will get well as soon as possible. With DOT, you may need to take medicine only 2 or 3 times each week instead of every day. The health care worker will make sure that the medicine is working as it should. This person will also watch for side effects and answer questions you have about TB.

Even if you are not getting DOT, you must be checked at different times to make sure everything is going well. You should see your doctor or nurse regularly while you are taking your medicine. This will continue until you are cured.

How important is treatment?

Treatment is vital. If you have TB disease, or if you have been infected with the bacteria but have not yet become sick, you must take the treatment as directed. It is very important to complete the full course of treatment, as it will stop you being infectious, and it will remove the risk of you developing drug-resistant TB.

What should you do if you think you might have TB?

Consult your doctor for advice. He or she may then refer you to a clinic for some simple tests. If you don’t have a family doctor, visit your local health center. They will refer you to TB-DOTS Center if they think you may have TB.

When should you get tested for TB?

You should get tested for TB if:

• You have spent time with a person with infectious TB
• You have HIV infection or another condition that puts you at high risk for TB disease
• You think you might have TB disease
• You are from a country where TB disease is very common (most countries in Latin America and the Caribbean , Africa , and Asia , except for Japan )
• You inject drugs
• You live somewhere in Philippines where TB disease is common (most homeless shelters, prisons and jails, and some nursing homes)

Your doctor or nurse may do some tests to see if you have TB disease. These tests usually include a chest x-ray and a test of the phlegm you cough up. Because the TB bacteria may be found somewhere besides your lungs, your doctor or nurse may check your blood or urine, or do other tests. If you have TB disease, you will need to take medicine to cure the disease.

What if you have been in contact with someone with TB?

Discuss this with your doctor. Only close contacts are at risk of catching TB. You may be asked to make an appointment with your local health center. The nurse will arrange a skin test and/or chest x-ray. This does not mean that you have TB, but it is a chance to check for any symptoms, so it is very important that you do attend, if asked.

Can TB be prevented?

Yes it can. Most important is early detection, especially of infectious cases, and complete treatment. Early case detection reduces onward transmission of the disease and a full course of treatment is vital to prevent the disease relapsing, to prevent the development of drug-resistant strains of TB, to prevent prolonged infectiousness and preventable death. Identifying cases who have been infected through screening contacts and offering preventive treatment to reduce the risk of infected persons developing TB also contributes to preventing TB. In hospitals and institutional settings infection control measures to identify and isolate infectious cases is important. In some high-risk groups and especially among infants and young children at risk of exposure to TB, BCG vaccination can offer some protection against TB but overall, BCG vaccination plays a limited role in TB control.

What is BCG vaccination?

• The BCG immunization increases a person’s immunity to TB and protects against the most severe forms of disease such as TB meningitis.
• The main recommendations for routine BCG vaccination of children are now: infants (aged 0 to 12 months) living in areas with a high incidence of TB (40/100,000 or greater), and any children with a parent or grandparent born in a high incidence country.

What if I Have Been Vaccinated with BCG?

BCG is a vaccine for TB. This vaccine is often given to infants and small children in the Philippines. BCG vaccine does not usually protect people from TB.

If you were vaccinated with BCG, you may have a positive reaction to a TB skin test. This reaction may be due to the BCG vaccine itself or to a real TB infection. But your positive reaction probably means that you have TB infection if:

• Your skin test reaction is large
• You were vaccinated many years ago (because the BCG reaction gets smaller over time)
• You have ever spent time with a person with infectious TB
• Someone in your family has had TB
• You are from a country where TB disease is very common (most countries in Latin America and the Caribbean , Africa , and Asia, except for Japan )

What is the difference between TB disease and TB infection?

In most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop them from growing. The bacteria become inactive, but they remain alive in the body and can become active later. This is called TB infection. People with TB infection:

• Have no symptoms
• Don’t feel sick
• Can’t spread TB to others
• Usually have a positive skin test reaction
• Can develop TB disease later in life

Most people who have TB infection will never develop TB disease. In these people, the TB bacteria remain inactive for a lifetime without causing disease. But in other people (for example, those who have weak immune systems), the bacteria may become active and cause TB disease.

What is TB disease?

TB bacteria become active if the immune system can’t stop them from growing. The active bacteria begin to multiply in the body and cause TB disease. Some people develop TB disease soon after becoming infected, before their immune system can fight the TB bacteria. Other people may get sick later, when their immune system becomes weak for some reason.

Babies and young children often have weak immune systems. People infected with HIV, the virus that causes AIDS, have very weak immune systems. Other people can have weak immune systems, too, especially people with any of these conditions:

• Substance abuse
• Diabetes mellitus
• Silicosis
• Cancer of the head or neck
• Leukemia or Hodgkin’s disease
• Severe kidney disease
• Low body weight
• Certain medical treatments (such as corticosteroid treatment or organ transplants)

Symptoms of TB depend on where in the body the TB bacteria are growing. TB bacteria usually grow in the lungs. TB in the lungs may cause:

• A bad cough that lasts longer than 2 weeks
• Pain in the chest
• Coughing up blood or sputum (phlegm from deep inside the lungs)

Other symptoms of TB disease maybe:

• Weakness or fatigue
• Weight loss
• No appetite
• Chills
• Fever
• Sweating at night

If you have TB Infection, How Can you protect yourself from Developing TB Disease?

Many people who have TB infection never develop TB disease. But some people who have TB infection are more likely to develop TB disease than others. These people are at high risk for TB disease. They include:

• People with HIV infection
• People in close contact with a person who has infectious TB
• People who became infected with TB bacteria in the last 2 years
• Babies and young children
• People who inject drugs
• People who are sick with other diseases that weaken the immune system
• Elderly people

If you have TB infection (a positive skin test reaction) and you are in one of these high-risk groups, you need to take medicine to keep from developing TB disease. This kind of treatment is called Treatment for Latent TB Infection.

People who have TB infection but do not receive this treatment need to know the symptoms of TB. If they develop symptoms of TB disease later on, they should see a doctor right away.

The medicine usually used for treatment latent TB infection is a drug called isoniazid or INH. INH kills the TB bacteria that are inactive in the body. If you take your medicine as prescribed, treatment of latent TB infection will keep you from developing TB disease.

Most people must take INH for at least 9 months. An effective alternative regimen that maybe considered is rifampin for 4 months daily.

Sometimes people are given treatment for latent infection even if their skin test reaction is not positive. This is often done with infants, children, and HIV-infected people who have recently spent time with someone with infectious TB disease. This is because they are at very high risk of developing serious TB disease soon after they become infected with TB bacteria and the skin test might be inaccurate in these people.

It is important that you take all the pills prescribed for you so that your treatment therapy is effective. If you start taking INH, you will need to see your doctor or nurse on a regular schedule. He or she will check on how you are doing. Very few people have serious side effects to INH. However, if you have any of the following side effects call your doctor or nurse right away:

• No appetite
• Nausea
• Vomiting
• Yellowish skin or eyes
• Fever for more 3 days
• Abdominal pain
• Tingling in the fingers and toes

Warning: Drinking excessive alcoholic beverages (wine, beer, and liquor) while taking INH can be dangerous. Check with your doctor or pharmacist for more information.

How Can I Keep from Spreading TB?

The most important way to keep from spreading TB is to take all your medicine, exactly as told by your doctor or nurse. You should also keep all of your doctor’s appointments! Your doctor or nurse needs to see how you are doing. You may need another chest x-ray or a test of the phlegm you may cough up. These tests will show whether the medicine is working. They will also show whether you can still give TB bacteria to others. Be sure to tell the doctor about anything you think is wrong.

If you are sick enough with TB to go to a hospital, you may be put in a special room. These rooms use air vents that keep TB bacteria from spreading. People who work in these rooms must wear a special face mask to protect themselves from TB bacteria. You must stay in the room so that you will not spread TB bacteria to other people. Ask a nurse if you need anything that is not in your room.

If you are infectious while you are at home, there are certain things you can do to protect yourself and others near you. Your doctor may tell you to follow these guidelines to protect yourself and others:

• The most important thing is to take your medicine.
• Always cover your mouth with a tissue when you cough, sneeze, or laugh. Put the tissue in a closed bag and throw it away.
• Do not go to work or school. Separate yourself from others and avoid close contact with anyone. Sleep in a bedroom away from other family members.
• Air out your room often (if it is not too cold outside). TB spreads in small closed spaces where air doesn’t move. Put a fan in your window to blow out (exhaust) air that may be filled with TB bacteria. If you open other windows in the room, the fan also will pull in fresh air. This will reduce the chances that TB bacteria stay in the room and infect someone who breathes the air.

Remember, TB is spread through the air. People cannot get infected with TB bacteria through handshakes, sitting on toilet seats, or sharing dishes and utensils with someone who has TB.

After you take medicine for about 2 or 3 weeks, you may no longer be able to spread TB bacteria to others. If your doctor or nurse agrees, you will be able to go back to your daily routine. Remember, you will get well only if your take your medicine exactly as your doctor or nurse tells you.

Think about people who may have spent time with you in the immediate period prior to your diagnosis, such as family members, close friends, and coworkers. The local health department may need to test them for TB infection. TB is especially dangerous for children and people with HIV infection. If infected with TB bacteria, these people need treatment for latent TB infection right away to keep from developing TB disease.

What if I Have HIV Infection?

A person can have TB infection for years without any signs of disease. But if that person’s immune system gets weak, the infection can quickly turn into TB disease. Also, if a person who has a weak immune system spends time with someone with infectious TB, he or she may become infected with TB bacteria and quickly develop TB disease.

Because HIV infection weakens the immune system, people with TB infection and HIV infection are at very high risk of developing TB disease. All HIV-infected people should be given a TB skin test to find out if they have TB infection. If they have TB infection, they need treatment of latent TB infection as soon as possible to prevent them from developing TB disease. If they have TB disease, they must take medicine to cure the disease.

TB disease can be prevented or cured in people with HIV infection.

What Is Multidrug-Resistant TB (MDR TB)?

When TB patients do not take their medicine as prescribed, the TB bacteria may become resistant to a certain drug. This means that the drug can no longer kill the bacteria.

Drug resistance is more common in people who:

• Have spent time with someone with drug-resistant TB disease
• Do not take their medicine regularly
• Do not take all of their prescribed medicine
• Develop TB disease again, after having taken TB medicine in the past
• Come from areas where drug-resistant TB is more common (former Soviet Union, Southeast Asia , Latin America , Haiti , and the Philippines )

Sometimes the bacteria become resistant to more than one drug. This is called multidrug-resistant TB, or MDR TB. This is a very serious problem. People with MDR TB disease must be treated with special drugs. These drugs are not as good as the usual drugs for TB and they may cause more side effects. Also, some people with MDR TB disease must see a TB expert who can closely observe their treatment to make sure it is working.

People who have spent time with someone sick with MDR TB disease can become infected with TB bacteria that are resistant to several drugs. If they have a positive skin test reaction, they may be given treatment for latent TB infection depends on the drug susceptibility profile of the person sick with TB. This is very important for people who are at high risk of developing MDR TB disease, such as children and HIV-infected people.

What is extensively drug resistant TB (XDR-TB)?

Multi-drug resistant (MDR) TB describes strains of TB that are resistant to at least isoniazid and rifampicin, two of the first line drugs used in the treatment of TB. Extensively drug resistant TB (XDR-TB) refers to MDR-TB that is also resistant to any of a group of drugs called fluoroquinolones and at least one of three injectable second line anti-TB drugs (capreomycin, kanamycin or amikacin). This revised definition of XDR-TB was agreed by the World Health Organization (WHO) Global Task Force on XDR-TB in October 2006.

Further information on XDR-TB can be found on the WHO website.

References:

New Jersey Medical School Global Tuberculosis Institute Website, 2013. About TB. [online] Available at: http://www.umdnj.edu/ntbc/ [Accessed 28 February 2013].

Health Protection Agency, 2011. Tuberculosis factsheet. [online] Availableat: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Tuberculosis/GeneralInformation/TBgen02factsheet/ [Accessed 28 February 2013].

ASK YOUR PHARMACIST: Frequently Asked Questions on Diabetes

What is diabetes?

Diabetes occurs when there are high levels of glucose (sugar) in the blood. All three types of diabetes involve problems with insulin, a hormone that removes glucose from the blood and allows it to enter the body’s cells. (The cells use it for energy.) If your body is unable to make or use insulin properly, you have a high blood glucose level. The disease cannot be cured but it can be controlled with lifelong treatment.

What are the types of diabetes?

There are 2 major types of diabetes mellitus.

• Type 1 occurs mostly in young people and requires regular insulin injections.
• Type 2 occurs mainly in older people. Some can be controlled with proper diet and exercise alone, but others may need medical treatment. Some may also need insulin injections. Many of those who suffer from Type 2 diabetes are overweight or obese.

What is gestational diabetes?

About 3% to 5% of pregnant weomen who have never had elevated blood glucose levels develop gestational diabetes, a form of diabetes that occurs only during pregnancy. As part of prenatal care, a pregnant woman should be screened for gestational diabetes between her 24th and 28th weeks of pregnancy. Many women who had gestational diabetes also eventually develop type 2 diabetes.

Babies born to mothers who had gestational diabetes during their pregnancy have a condition called macrosomia, which risks damage to their shoulders during birth. Such newborns may have very low blood glucose levels at birth. They are also at higher risk of developing breathing problems, obesity, and type 2 diabetes as adults.

What are the risk factors for developing gestational diabetes?

• Advancing age. Women older than 40 are more than twice as likely to develop it as women ages 25 to 29.
• History of diabetes in a first-degree relative. The risk is more than 1.5 times greater than in women without a history.
• Nonwhite ethnicity. The risk is 1.45 times greater for Hispanics, 1.75 times greater for African Americans, and 2.32 times greater for Asians.
• High body mass index (BMI) before pregnancy. A pre-pregnancy BMI of 25 to 29.9 doubles the risk. The risk triples with a BMI of 30 or more.
• Weight gain in early adulthood. A high BMI at age 18 greatly increases the risk.
• Cigarette smoking
• Previously bearing a child who weighed more than nine pounds
• Previously having a stillbirth of unknown cause

What is hyperglycemia?

This is a condition in which the level of sugar in the blood is excessively high. It happens when the body has too little or not enough insulin, or when the body cannot respond to the insulin properly.

What is hypoglycemia?

The medical name for low blood sugar, hypoglycemia is a common complication of diabetes. When someone who does not have diabetes is diagnosed with hypoglycemia, it is usually a signal of a serious problem, e.g., an insulin-secreting tumor or liver disease.

What are the symptoms of diabetes?

For type 1 or type 2 diabetes:

• Elevated blood sugar levels (hyperglycemia)
• increased appetite (polyphagia)
• increased urination (polyuria)
• increased thirst (polydypsia)

For gestational diabetes:

• Initially, excess weight
• Decreased energy
• Decreased appetite
• Eventually, sudden weight loss

What are the complications of having diabetes?

• Severe hyperglycemia with too much acid in the body — can cause confusion and loss of body consciousness
• high blood pressure, heart disease, stroke, kidney damage
• blindness (due to retinal damage), cataracts, other eye disorders
• Poor healing of wounds
• Gangrene (tissue death) when the blood supply is cut off, usually in the toes and feet
• Infection in skin and soft tissues, vaginal infection
• Numbness (due to nerve damage) with loss of sensation, especially in the feet

What causes diabetes?

• Heredity
• An autoimmune disorder, where the body’s defenses attack and destroy the cells in the pancreas that produce insulin
• A viral infection that damages the pancreas and sets off an autoimmune process
• Lifestyle and diet

What can one do in relation to diabetes?

• If you think you have diabetes, consult a doctor.
• If you are confirmed to have type 1 or type 2 diabetes, strictly follow your doctor’s recommendations for keeping your diabetes under control.
• Stick to a lifelong low-sugar, low-fat, high-fiber diet. If overweight, lose weight and maintain ideal body weight. Diet and weight management are often enough to keep type 2 diabetes in check and may prevent diabetes-prone people from developing diabetes.
• Exercise regularly.
• Regularly look over your body, especially the feet, for wounds or infection. Never walk barefoot. Wash your feet daily, dry them thoroughly, and apply talcum powder. Take extra care when cutting your fingernails and toenails. Shave with care.
• Practice good hygiene.
• Maintain good dental health.
• Take prescribed medicines religiously. Never stop medication without consulting your doctor.
• Monitor your blood or urine sugar regularly, whether you are diabetic or nondiabetic (especially when a member of the family is diabetic).
• If you experience any symptoms of gestational diabetes, call your doctor immediately. If you are confirmed to have the condition, work with your doctor to modify the factors that you can. Lose excess weight, exercise, and eat healthy. If you smoke, quit.

Reference:

Health Guide – Guide to Common Medical and Health Conditions. 14th Edition. 2008-2009.

ASK YOUR PHARMACIST: Frequently Asked Questions on Breast Cancer

What is breast cancer?

Breast cancer occurs when a malignant tumor forms in the breast tissue. The cancer can be found in the breast itself or in the ducts and lymph nodes that surround the breast.

What is metastatic breast cancer?

When cancer spreads from its original location in the breast to another part of the body such as the brain, it is called metastatic breast cancer, not brain cancer. Doctors sometimes call this “distant” disease.

Do men get breast cancer?

Yes. Although breast cancer is primarily a woman’s disease, men can get breast cancer too. They can develop it at any age, but they are usually between 60 and 70 years of age when the diagnosis is made. Male breast cancer makes up less than 1 percent of all cases of breast cancer.

What is the most important risk factor for breast cancer?

Older age is a major risk factor. Three-fourths of all breast cancers occur in women age 50 or older. Having a sister, mother, or daughter who has had breast cancer also increases your risk.  This chart shows what the approximate chances are of a woman getting invasive breast cancer in her lifetime.

Ages	Chances
30 to 40…     |    Chances are 1 out of 257
40 to 50…     |    Chances are 1 out of 67
50 to 60…     |    Chances are 1 out of 36
60 to 70…     |    Chances are 1 out of 28
70 to 80…     |    Chances are 1 out of 24

What are the symptoms of breast cancer?

When breast cancer first develops, there may be no symptoms at all. But as the cancer grows, it can cause changes that women should watch for. You can help safeguard your health by learning the following warning signs of breast cancer:
• a lump or thickening in or near the breast or in the underarm area.

• a change in the size or shape of the breast.

• ridges or pitting of the breast; the skin looks like the skin of an orange.

• a change in the way the skin of the breast, areola, or nipple looks or feels; for example, it may be warm, swollen, red, or scaly.

• nipple discharge or tenderness, or the nipple is pulled back or inverted into the breast.

Breast Cancer Symptoms

Should I perform regular breast self-exams?

Doing a breast self-exam may help a woman detect a lump that might otherwise go unnoticed. However, most health organizations currently recommend clinical breast exams done by a doctor or trained expert, or mammograms, as the most reliable tools for detecting breast cancer.

What happens during a clinical breast exam?

During a clinical breast exam, a doctor or other health care professional checks the breasts and underarms for lumps or other changes that could be a sign of breast cancer. The doctor can tell a lot about a lump by carefully feeling it and the tissue around it. Benign lumps often feel different from cancerous ones.

What happens during a mammogram?

Mammography is a simple procedure. A registered technologist takes an x-ray of each breast with a machine that is used only for breast x-rays. It is different from x-ray machines that are used to take x-rays of the bones or other parts of the body. The standard mammogram exam includes two views of each breast, one from above and one angled from the side.  The technologist places the breast between two flat plastic plates. The two plates are then pressed together. The idea is to flatten the breast as much as possible. Spreading the tissue out makes any abnormal details easier to spot with a minimum of radiation. The technologist takes the x-ray, and then repeats the procedure for the next view. The pressure from the plates may be uncomfortable, or even slightly painful, but each x-ray takes less than one minute.

What are some of the possible benefits of a mammogram?

A mammogram can often detect breast changes in women who have no signs of breast cancer. Often, it can find a breast lump before it can be felt. If the results indicate that cancer might be present, your doctor will advise you to have a follow-up test called a biopsy.

Is there any danger in having a mammogram?

Some women worry about radiation exposure, but the risk of any harm from a mammogram is actually quite small. The doses of radiation used are very low and considered safe. The exact amount of radiation used during a mammogram will depend on several factors. For instance, breasts that are large or dense will require higher doses to get a clear image.

If a breast exam or mammogram does indicate the possibility of cancer, what happens next?

If the results of a clinical breast exam or a mammogram indicate that cancer might be present, the doctor will order a follow-up test. The most common follow-up test is called a biopsy. This is a procedure where a doctor removes a small amount of fluid or tissue from the breast to make a definitive diagnosis. A doctor might perform fine needle aspiration, a needle or “core” biopsy, or a surgical biopsy.

If I do need to seek treatment for breast cancer, what are some of my options?

You can seek conventional treatment from a specialized cancer doctor, called an oncologist. The oncologist will usually assemble a team of specialists to guide your therapy. Besides the oncologist, the team may include a surgeon, a radiation oncologist who is a specialist in radiation therapy, and others.

Before treatment begins, I have heard that the doctor will stage the cancer. What is staging?

Once breast cancer has been found, it is staged. Staging means determining how far the cancer has progressed. Through staging, the doctor can tell if the cancer has spread and, if so, to what parts of the body. More tests may be performed to help determine the stage. Knowing the stage of the disease helps the doctor plan treatment. Staging will let the doctor know

• the size of the tumor and exactly where it is in the breast.

• if the cancer has spread within the breast.

• if cancer is present in the lymph nodes under the arm.

• If cancer is present in other parts of the body.

What are the standard types of treatment for breast cancer?

Standard treatments for breast cancer include:

• surgery that takes out the cancer

• radiation therapy that uses high-energy beams to kill cancer cells and shrink tumors

• chemotherapy that uses anti-cancer drugs to kill cancer cells

• hormone therapy that keeps cancer cells from getting the hormones they need to survive and grow.

What kinds of surgery are available for women with breast cancer?

Surgery, as opposed to chemotherapy or radiation, is the most common treatment for breast cancer. The kind of surgery a woman has is based on the type and stage of the cancer. Most women can choose between breast-conserving surgery that removes the cancer but not the breast, or surgery that removes the entire breast and sometimes the surrounding tissue.

What is involved in breast-conserving surgery?

There are two types of breast-conserving surgery — lumpectomy and partial mastectomy.

• Lumpectomy is the removal of the tumor and a small amount of normal tissue around it. A woman who has a lumpectomy almost always has radiation therapy as well. Most surgeons also take out some of the lymph nodes under the arm.

• Partial or segmental mastectomy is removal of the cancer, some of the breast tissue around the tumor, and the lining over the chest muscles below the tumor. Often, surgeons remove some of the lymph nodes under the arm. In most cases, radiation therapy follows.

What does a mastectomy involve?

Surgery to remove the entire breast and sometimes the surrounding tissue is called a mastectomy. There are three types:

• A total or simple mastectomy is removal of the whole breast. Sometimes the surgeon takes out lymph nodes under the arm as well.

• A modified radical mastectomy is removal of the breast, many of the lymph nodes under the arm, and the lining over the chest muscles. Sometimes, the surgeon removes part of the chest wall muscles, too.

• A radical mastectomy, sometimes called the Halsted radical mastectomy, is removal of the breast, chest muscles, and all of the lymph nodes under the arm. This surgery is used only when the tumor has spread to the chest muscles.

Are there any treatments that follow surgery?

Even if the surgeon removes all of the cancer that can be seen at the time of surgery, a woman may still receive follow-up treatment. This may include radiation therapy, chemotherapy, or hormone therapy to try to kill any cancer cells that may be left. Treatment that a patient receives after surgery to increase the chances of a cure is called adjuvant therapy.

How is radiation therapy used to treat breast cancer?

Radiation therapy uses high-energy x-rays or other types of radiation to kill cancer cells and shrink tumors. This therapy often follows a lumpectomy, and is sometimes used after mastectomy. During radiation therapy, a machine outside the body sends high-energy beams to kill the cancer cells that may still be present in the affected breast or in nearby lymph nodes. Doctors sometimes use radiation therapy along with chemotherapy, or before or instead of surgery.

How is chemotherapy used to treat breast cancer?

Chemotherapy is the use of drugs to kill cancer cells. A patient may take chemotherapy by mouth in pill form, or it may be put into the body by inserting a needle into a vein or muscle. Either type of chemotherapy is called whole body or systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells throughout the body. Treatment with chemotherapy can be as short as two months or as long as two years.  Sometimes chemotherapy is the only treatment the doctor will recommend. More often, however, chemotherapy is used in addition to surgery, radiation therapy, and/or biological therapy.

How is hormonal therapy used to treat breast cancer?

Hormonal therapy keeps cancer cells from getting the hormones they need to grow. This treatment may include the use of drugs that change the way hormones work. Sometimes it includes surgery to remove the ovaries, which make female hormones. Like chemotherapy, hormonal therapy can affect cancer cells throughout the body.  Often, women with early-stage breast cancer and those with metastatic breast cancer — meaning cancer that has spread to other parts of the body — receive hormone therapy in the form of tamoxifen. Hormone therapy with tamoxifen or estrogens can act on cells all over the body. However, it may increase the chance of developing endometrial cancer. If you take tamoxifen, you should have a pelvic examination every year to look for any signs of cancer. A woman should report any vaginal bleeding, other than menstrual bleeding, to her doctor as soon as possible.

What drugs are available?

Certain drugs that have been used successfully in other cancers are now being used to treat some breast cancers. For example, some women take the chemotherapy drug paclitaxel in combination with the drugs cyclophosphamide and doxorubicin to help kill tumors that have spread to other parts of the body. This mix of drugs may increase the length of time you will live, or the length of time you will live without cancer.  In addition, certain drugs like Herceptin® and Tykerb® taken in combination with chemotherapy, can help women with specific genetic breast cancer mutations better than chemotherapy alone.

What is the best way to prevent breast cancer?

Several methods show promise in reducing breast cancer risk. In October 1998, the Food and Drug Administration approved the drug tamoxifen to lower the risk of breast cancer in high-risk women. Following a large-scale study, researchers found that tamoxifen reduced cancer in high-risk women by about 50 percent.  Another method is a type of surgery called preventive or prophylactic mastectomy for women at high risk of breast cancer. It involves removing a breast that is not known to contain cancer in order to reduce a woman’s cancer risk.

What is the relationship between lifestyle and breast cancer?

Some researchers are looking at diet as a possible risk factor for breast cancer. Studies show that women in populations that consume a high-fat diet are more likely to die of breast cancer than women in populations that consume a low fat diet. But scientists still do not know for sure if a diet low in fat will lower the risk of breast cancer, or if any other specific dietary changes will actually prevent cancer.  Some studies point to lifestyle choices that may decrease a woman’s risk of breast cancer. Exercise, especially in young women, may decrease hormone levels and contribute to a decreased risk. Breast-feeding also may decrease risk.  Other studies point to lifestyle factors that might increase a woman’s risk of developing breast cancer. For instance, women who drink alcohol have a slightly increased risk. Gaining weight after menopause, especially after natural menopause and/or after age 60, also may increase a woman’s risk.

Are there new studies under way to try and reduce a woman’s chance of getting breast cancer?

Yes. Researchers are currently looking at substances called aromatase inhibitors that might also help reduce risk. Aromatase inhibitors prevent the formation of estradiol, which is a female hormone. Women who are post-menopausal and whose breast cancer is hormone-dependent may respond well to this therapy.  New research shows women with early-stage breast cancer who took the drug letrozole, an aromatase inhibitor, after they completed five years of tamoxifen therapy significantly reduced their risk of breast cancer recurrence.  Also, other new research found a test that can predict both the risk of breast cancer recurrence and who is most likely to benefit from chemotherapy such as letrozole.  Another study, known as TAILORx, was launched by the National Cancer Institute in May 2006, to examine whether genes that are frequently associated with risk of recurrence for women with early-stage breast cancer can be used to assign patients to the most appropriate and effective treatment.

Source: Philippine Cancer Society, Inc.