Environmental Articles Archive: Human Health
Web version prepared by BCAS
June, 2008

Resurgence of malaria

The resurgence of malaria in some Asian and African countries has become a matter of concern for governments and doctors, as the disease and the mosquitoes that carry it are increasingly developing resistance to the traditional methods of control. 

Reports from Brazil and South-East Asia, in particular, show that insecticides like DDT no longer work, and some of the bacteria which mosquitoes inject into the patients' blood have become immune to drugs like chloroquine. So the number of deaths and debilitations caused by malaria has been on the rise in some third world countries. 

Many countries have stepped up their anti-malaria campaigns, some of which had stopped in the 1960s. The remarkable success of DDT (when first used) against malaria bearing (female anopheles) mosquitoes gave the authorities the false hope that the disease could be eradicated. But both the insects and the bacteria have a surprising ability to develop resistance against drugs and insecticides. 

That is why more and more attention is today being given to the possibility of tackling malaria by preventing the breeding of mosquitoes and adopting other mechanisms to protect the people from mosquito attacks. 

In some developing countries, both adults and children are given training on how to reduce breeding sites, and to monitor and also identify mosquitoes in their areas.

Meanwhile, the first World Malaria Day on April 25 was observed in our country as elsewhere across the globe to create awareness among the people about the preventable disease which claims at least 500 lives and affects more than 60,000 people in Bangladesh annually. Malaria claims at least one million lives annually all over the world.

The day was observed through discussions, rallies and dramas to create awareness among the people about the disease, and about measures for prevention and early detection. 

The outbreak of malaria in our country is the highest in 70 upazilas of 13 districts with a population of about 10.9 million. Most malaria affected people are in the districts of Rangamati, Bandarban, Khagrachari, Cox's Bazar, Chittagong, Netrokona, Mymensingh, Habiganj, Moulvibazar, Sylhet, Sunamganj, Sherpur and Kurigram. 

According to Shaheen Akhter, a consultant under Global Fund for HIV/AIDS/TB and Malaria (GFATB), the government has started a program that aims at reducing malaria by 50% by the year 2012. Five lakh long-lasting insecticide treatable mosquito nets were distributed among the ultra poor people in malaria prone districts last year. The number will be increased to seven lakh, she said. 

It is alleged that some of these nets have been found in the houses of comparatively privileged people. According to Shaheen Akhter the allegations are not without basis. Steps are being taken so that the nets reach the target groups for whom they are meant, she said. 

According to Dr. A Raqib, Deputy Program Manager, Malaria Control Program under GFATM, Bangadesh, as a part of five-year program, has received $40 million, which is being channeled through government agencies and NGOs like Brac. 

According to him, the government and the NGOs have been working to promote quality diagnosis and effective treatment to at least 80% of the malaria cases. The government agencies and NGOs are engaged in promoting use of long-lasting insecticide treatable mosquito nets and creating awareness among the people as preventive measures. Under GFATM, steps are being taken for strengthening program management capacity, and coordination and partnership in malaria control, he said.

Rapid diagnostic test is gradually being made available in rural areas in the malaria prone districts, where one field health worker has been assigned to look after 5000-7000 people. According to Shaheen Akhter, under the GFATM, some NGOs have been tasked with setting up microscopic laboratories (diagnostic centers) in remote areas for quick detection through proper diagnosis so that malaria patients can get timely treatment.

A couple of decades ago a Chinese doctor named Dr. Li invented a new cure, which does not have any side effects, for this deadly disease. Dr. Li Guqiao was the son of a traditional doctor, and deputy president of Canton College of Traditional Chinese medicine. He and his group reportedly discovered Ginghaosu's (active principle of the green herb) potential for preventing malarial infection. 

The process of synthesising Ginghaosu has proved prohibitively expensive, but a cheaper soluble derivative of the natural extract is reportedly being developed. But it is not known whether the drug, already in use in China, has got necessary approval for marketing. 

It is largely believed that malaria control programs will succeed in the context of third world countries like Bangladesh through community participation, in the absence of trained personnel and adequate financial resources. Let us hope that the concerned authorities will give necessary consideration to this aspect while continuing their various activities in this regard, including prevention and control. 

Nurul Huda is a Special Correspondent of BSS. 

Source: The Daily Star, June 18, 2008

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Water contaminated with feces causes Typhoid

Typhoid fever, also known as enteric fever, bilious fever or Yellow Jack, is an illness caused by the bacterium Salmonella enterica serovar Typhi. Common worldwide, it is transmitted by the ingestion of food or water contaminated with feces from an infected person. The bacteria then multiply in the blood stream of the infected person and are absorbed into the digestive tract and eliminated with the waste. The organism is a Gram-negative short bacillus that is motile due to its peritrichous flagella. The bacteria grows best at 37°C (human body temperature).

Symptoms: Typhoid fever is characterized by a sustained fever as high as 40°C (104°F), profuse sweating, gastroenteritis, and nonbloody diarrhea. Less commonly a rash of flat, rose-colored spots may appear.

Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache and cough. Epistaxis is seen in a quarter of cases and abdominal pain is also possible.

There is leukopenia with eosinopenia and relative lymphocytosis, a positive diazo reaction and blood cultures are positive for Salmonella Typhi or Paratyphi. The classic Widal test is negative in the first week.

In the second week of the infection, the patient lies prostrated with high fever in plateau around 104°F (40°C) and bradycardia (Sphygmo-thermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and abdomen in around 1/3 patients. There are rhonchi in lung bases. The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to pea-soup. However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly) and tender and there is elevation of liver transaminases. The Widal reaction is strongly positive with antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage. In the third week of typhoid fever a number of complications can occur:

Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually non-fatal. 

Intestinal perforation in distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in. Encephalitis : Metastatic abscesses, cholecystitis, endocarditis and osteitis 

The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is delirious (typhoid state). By the end of third week defervescence commences that prolongs itself in the fourth week. Diagnosis: Diagnosis is made by blood, bone marrow or stool cultures and with the Widal test (demonstration of salmonella antibodies against antigens O-somatic and H-flagellar). In epidemics and less wealthy countries, after excluding malaria, dysentery or pneumonia, a therapeutic trial time with chloramphenicol is generally undertaken while awaiting the results of Widal test and blood cultures.

Treatment: Doctor administering a typhoid vaccination at a school in San Augustine County, Texas. Photograph by John Vachon, April 1943.Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, and ciprofloxacin, have been commonly used to treat typhoid fever in developed countries. Prompt treatment of the disease with antibiotics reduces the case-fatality rate to approximately 1%. When untreated, typhoid fever persists for three weeks to a month. Death occurs in between 10% and 30% of untreated cases.

Resistance: Resistance to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole and streptomycin is now common, and these agents have not been used as first line treatment now for almost 20 years. Typhoid that is resistant to these agents is known as multidrug-resistant typhoid (MDR typhoid).

Ciprofloxacin resistance is an increasing problem, especially in the Indian subcontinent and Southeast Asia. Many centres are therefore moving away from using ciprofloxacin as first line for treating suspected typhoid originating in India, Pakistan, Bangladesh, Thailand or Vietnam. For these patients, the recommended first line treatment is ceftriaxone.

There is a separate problem with laboratory testing for reduced susceptibility to ciprofloxacin: current recommendations are that isolates should be tested simultaneously against ciprofloxacin (CIP) and against nalidixic acid (NAL), and that isolates that are sensitive to both CIP and NAL should be reported as "sensitive to ciprofloxacin", but that isolates testing sensitive to CIP but not to NAL should be reported as "reduced sensitivity to ciprofloxacin". However, an analysis of 271 isolates showed that around 18% of isolates with a reduced susceptibility to ciprofloxacin (MIC 0.125-1.0 mg/l) would not be picked up by this method. It not certain how this problem can be solved, because most laboratories around the world (including the West) are dependent disc testing and cannot test for MICs.

Prevention: Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid does not affect animals and therefore transmission is only from human to human. Typhoid can only spread in environments where human faeces or urine are able to come into contact with food or drinking water. Careful food preparation and washing of hands are therefore crucial to preventing typhoid. There are two vaccines currently recommended by the World Health Organisation for the prevention of typhoid: these are the live, oral Ty21a vaccine (sold as Vivotif Berna) and the injectable Vi capsular polysaccharide vaccine (sold as Typhim Vi). Both are between 50 to 80% protective and are recommended for travellers to areas where typhoid is endemic. There exists an older killed whole-cell vaccine that is still used in countries where the newer preparations are not available, but this vaccine is no longer recommended for use, because it has a higher rate of side effects (mainly pain and inflammation at the site of the injection). Transmission: Death rates for Typhoid Fever in the U.S. 1906-1960Flying insects feeding on feces may occasionally transfer the bacteria through poor hygiene habits and public sanitation conditions. Public education campaigns encouraging people to wash their hands after toileting and before handling food are an important component in controlling spread of the disease. According to statistics from the United States Center for Disease Control, the chlorination of drinking water has led to dramatic decreases in the transmission of typhoid fever in the U.S.

A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms, but capable of infecting others. According to the Centers for Disease Control approximately 5% of people who contract typhoid continue to carry the disease after they recover. The most famous asymptomatic carrier was Typhoid Mary. She was a young cook that was responsible for infecting about 47 people during her lifetime, killing three of the infected. This was the first time a perfectly healthy person was known to be responsible for an "epidemic".

Epidemiology: With an estimated 16-33 million cases of annually resulting in 500,000 to 600,000 deaths in endemic areas, the World Health Organisation identifies typhoid as a serious public health problem. Its incidence is highest in children between 5 and 19 years old.[8]

Heterozygous advantage: It is thought that cystic fibrosis may have risen to its present levels (1 in 1600 in UK) due to the heterozygous advantage that it confers against typhoid fever. The CFTR protein is present in both the lungs and the intestinal epithelium, and the mutant cystic fibrosis form of the CFTR protein prevents entry of the typhoid bacterium into the body through the intestinal epithelium.

History: Around 430-426 B.C., a devastating plague, which some believe to have been typhoid fever, killed one third of the population of Athens, including their leader Pericles. The balance of power shifted from Athens to Sparta, ending the Golden Age of Pericles that had marked Athenian dominance in the ancient world. Ancient historian Thucydides also contracted the disease, but he survived to write about the plague. His writings are the primary source on this outbreak. The cause of the plague has long been disputed, with modern academics and medical scientists considering epidemic typhus the most likely cause. However, a 2006 study detected DNA sequences similar to those of the bacterium responsible for typhoid fever.[9] Other scientists have disputed the findings, citing serious methodologic flaws in the dental pulp-derived DNA study. The disease is most commonly transmitted through poor hygiene habits and public sanitation conditions; during the period in question, the whole population of Attica was besieged within the Long Walls and lived in tents.

In the late 19th century, typhoid fever mortality rate in Chicago averaged 65 per 100,000 people a year. The worst year was 1891, when the typhoid death rate was 174 per 100,000 persons. The most notorious carrier of typhoid fever-but by no means the most destructive-was Mary Mallon, also known as Typhoid Mary. In 1907, she became the first American carrier to be identified and traced. She was a cook in New York; some believe she was the source of infection for several hundred people. She is closely associated with forty-seven cases and three deaths. Public health authorities told Mary to give up working as a cook or have her gall bladder removed. Mary quit her job but returned later under a false name. She was detained and quarantined after another typhoid outbreak. She died of pneumonia after 26 years in quarantine. In 1897, Almroth Edward Wright developed an effective vaccine.

Most developed countries saw declining rates of typhoid fever throughout first half of 20th century due to vaccinations and advances in public sanitation and hygiene. Antibiotics were introduced in clinical practice in 1942, greatly reducing mortality. At the present time, incidence of typhoid fever in developed countries is around 5 cases per 1,000,000 people per year.

An outbreak in the Democratic Republic of Congo in 2004-05 recorded more than 42,000 cases and 214 deaths.

Source: The New Nation, June 22, 2008

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Woeful Life Of Tannery Workers 
Toxic chemicals taxing health
Shahnaz Parveen

Mohammad Babul, a 40-year-old tannery worker suffering from severe skin diseases and other complications, has lost confidence in modern medicines. 

Workers at Hazaribagh tanneries still work without any protective garbs exposing themselves to serious health hazards. In the picture, top, chemical waste being collected in an open reservoir, bottom left, a worker churning chemical waste in bare hand, bottom right, working on a chemical-drenched floor without any gloves or shoes.

“Medicines do not work on me anymore. I suffer from skin diseases, allergy and chest pain but my problems automatically go away when I don't work,” he said. 

Born in the city's Hazaribagh area, Babul has the only skill --that is processing animal hides with deadly chemicals. His work involves soaking the skins in chemical-mixed water, liming and de-liming, scrapping off meat and fat and removing hair from rawhides, and finally tanning. And all this is done with bare hands. 

Every day he is exposed to poisonous chemicals like chromium, sulphur, manganese, copper compound, lead and many more. 

According to experts, the dangerous mixture of chemicals, acids and dyes used in the tanneries are extremely hazardous to human body. 

Babul's doctor advised him to leave the leather-tanning job if he wants to stay healthy. But he cannot even think about this. “I cannot stop working at the tannery as I have a family to feed. At this age where will I find a new job?” he said. 

Meanwhile, at Hazaribagh dirt, blood, raw skins and animal wastes lying here and there in a very unhygienic environment is a usual scene in the tanneries. Around 20,000 tannery workers are forced to continue working in this hazardous condition. 

Nearly 90 percent tanneries of the country are in Hazaribagh. According to official statistics, 198 tanneries are located on 25 hectares of land in Hazaribagh area. There are a few in Jessore, Chittagong and one in Savar.

Surrounded by high walls and with very little ventilation, the air inside the factories is suffocating with fumes, heat and odour of chemicals. While large factories have some facilities, the condition in smaller factories is deplorable. 

The dreadful stink of the Hazaribagh tannery district can be smelt from miles away, all the way to the residential areas like Rayerbazar, Jhigatola and parts of Dhanmondi. 

Hazaribagh is usually avoided by the city dwellers. No one wants to live in Hazaribagh or even go to the place for a short visit. Only those associated with the tannery industry live in this area.

Small tanneries process hide extracted from animal waste unused by the larger factories. Re-use of chemical mixed liquid waste is a regularly practised by the small factories to process rawhide, making the situation even worse. 

Dr Ajoy Kumar Das, a professor at the Department of Applied Chemistry and Chemical Technology, Dhaka University, explained the hazards that tannery workers face.

“Workers at tanneries come in contact with a dangerous mix of chemicals in every step of their work, especially during the first stage of processing rawhide,” he said. 

Around 30 to 40 types of heavy metal chemical compounds and acids are used to process rawhides. Among them the most dangerous are chromium, sulphur, manganese, copper compound and lead, Das told Star City. These chemicals are used for making wet blue leather from rawhides. 

Most workers are directly exposed to these chemicals every day as the entire process is done manually. They do not use hand gloves or any other protective gears. 

Around 30 export-oriented factories offer their workers protective gears while the rest pay little attention to their health and security.

During a visit to Hazaribagh this correspondent found none of the workers using special suits, masks, gloves and special shoes to protect themselves from toxic chemicals. Most of the workers were found working with bare feet and hands while the floors of the factories were littered with dirt, blood and chemicals. 

Most workers complained of various complications such as nausea and headache. Jaundice is another common illness among them. Prof Das gives details of the illness that tannery workers suffer from. 

Generally, these chemicals can cause allergy, boils, inflammation in hands and legs, skin diseases and infection. However, if exposed for longer period they can even cause cancer. 

Prof Das explained that during work these chemicals evaporate and mix with the air. Inhalation of this vapour damages lungs and causes respiratory illness such as asthma and bronchitis. It reaches the digestive system and causes diarrhoea. The vapour also damages eyes and the nerve system after touching the skin.

After tanning comes the process of finishing leather. A huge amount of dyes, pigments and chemicals are used again. During making the finished products, leather particles mix with the air and also cause respiratory problems of workers. 

Most workers said some of the illnesses automatically disappear when they take a leave or stop working temporarily.

According to a survey conducted by the Society for Environment and Human Development (SEHD), around 90 percent of the tannery workers are suffering from at least one of the above-mentioned illnesses. 

The SEHD report says that 58 percent of the tannery workers suffer from gastrointestinal diseases, 31 percent from dermatological diseases, 12 percent from hypertension and 19 percent from jaundice.

The plight of the workers does not end here. Majority of the workers are recruited on temporary basis and are deprived of fair wages and other benefits. 

Temporary workers do not enjoy weekly holidays. With overtime, majority of the workers work around 16 hours a day. There is also night shift. Women workers are always paid less amount of wages. They do not enjoy maternity leave. 

Abul Kalam Azad, president, Hazaribagh Tannery Workers Union, said tannery owners pay very little attention to the health of the workers. 

“In every two years we have formal talks with the owners. We place our demands. Contracts are also signed regularly but nothing changes,” Azad said. 

“Workers keep on working in hazardous condition with regular illness as part of their life and without additional health benefits to ease their pain. Very few tanneries provide protective gears for workers. Lack of ventilation remains the same,” he added. 

Azad mentioned that for lack of awareness workers also do not take these factors seriously. They are more interested in salary increase. 

“Owners fail to understand that a good working environment means healthy workers which will eventually ensure good production and revenues,” he added. 

Harun-or-Rashid, managing director, Lexco Ltd, puts the blame on workers instead. “We provide protective gears to workers but they do not use them. It is not possible to supervise them all the time.” 

“However, it will be possible to improve the condition once the tanneries are relocated to the proposed modern leather estate in Savar. Systems will be updated there and it will definitely change the working environment,” he said.

Tipu Sultan, president, Bangladesh Finished Leather, Leather Goods and Footwear Exporters' Association, on the other hand blamed small tannery owners. 

“Owners with small investment cannot afford modern machines so they process leather manually. They cannot afford protective gears either," he said. A little support from the government can change the situation, Sultan added. 

Both the workers and owners stressed quick relocation of tanneries from Hazaribagh and setting up a more modern facility.

Hazaribagh tannery district is solely responsible for serious pollution in and around the area. The untreated tannery waste is one of the most hazardous and toxic wastes. Residents in Hazaribagh area have been complaining for a long time that the tanneries spread bad odour and pollute the air beyond tolerable limits.

According to the Department of Environment (DoE), nearly 22,000 cubic metres of untreated and highly toxic liquid waste is discharged by the tanneries every day into the water bodies including the River Buriganga, the lifeline of the capital.  Aquatic life forms of the Buriganga are seriously threatened. 

Moreover, every day 100 tonnes of solid waste including trimmings of finished leather, shaving dusts, hair, fleshing, trimming of raw hides and skins are dumped into the Buriganga and nearby land contaminating the soil and water. 

In 2003, the then government took up a Tk 175 crore project to shift the tanneries to a 'leather estate' in Savar. The project was inaugurated in 2005. 

The deadline for relocating the tanneries to Savar is 2010. Sources said complexities in setting up the Common Effluent Treatment Plant (CETP) is hindering the process of shifting the tanneries. Tannery owners are also reluctant to shift their business until the government provides them with compensations and other facilities.

Source: The Daily Star, June 22, 2008

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Over 38,000 people affected with arsenic-related diseases 

KHULNA, June 24 (UNB): Over 38,000 people in the country were affected with arsenic-related diseases while water of 30 per cent tubewells contaminated with arsenic till 2006, according to a government survey.

The number of patients may rise if the latest results of the division wise surveys are published, said a Health Department workshop here Tuesday.

Arsenic Programme of the Health Ministry and Department held the monitoring and evaluation workshop on "Searching of Arsenicosis Patients and Management".

It also said Water of some 1.44 million tube-wells in 270 upazilas of 62 districts were contaminated with arsenic while 66.0 million tubewells identified as vulnerable. 

Dr AKM Mujibur Rahman, NCD and OPHE Programme Officer, presided the workshop, addressed, among others, by Deputy Secretary (Administra-tion) of Health and Family Welfare Mahfuzul Huq, Divisional Deputy Director of Health Department Dr Zebunnesa Khatun and district Civil Surgeon Dr Maksuda Begum. In Bangladesh, arsenic contamination of ground water was first detected in 1993 by the Department of Public Health Engineering (DPHE) at Sama village of Baroghoria union in Sadar Upazila of Chapainawabganj district. After testing water in different districts, some eight arsenic patients were detected in 1995. The number rose to 23 in 1996 while 42 in '97 and 60 in 98. And the number stood at 38,412 in 2006.

Some 5,120 arsenicosis patients were detected in Khulna division due to consumption of arsenic contaminated water. District-wise break up of patients are : Khulna - 420, Jessore - 1,537, Bagerhat - 490, Satkhira - 194, Narail - 107, Magura - 174, Jhenidah - 312, Chuadanga - 815, Kushtia - 637 and Meherpur - 373. The workshop was informed that the government has undertaken different arsenic mitigation programmes. Medicines have already been sent to different district and upazila health complexes through CMSD. The government has initiated to take rehabilitation programme for the arsenicosis patients. 

Source: The Financial Express, June 25, 2008

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Migratory birds responsible for bird flu: Study

Migratory birds are mainly responsible for the outbreak of avian influenza (AI) or bird flu in the country, according to a study report.

The report said that migratory birds might be responsible for initial introduction of highly pathogenic avian influenza (HPAI) in Bangladesh.

Bangladesh Livestock Research Institute (BLRI), Bangladesh Agriculture University, Chittagong Veterinary University, Department of Livestock Service and Food and Agricultural Organisation (FAO) jointly conducted the study from February to June this year.The study involved phylogenetic, epidemiological and socio-economic analysis.

The research findings were presented at a seminar at BLRI in Savar. Former vice chancellor of Bangladesh Agriculture University Prof Dr MU Ahmed Chowdhury was present as the chief guest and BLRI Director General Dr Jahangir Alam presided over the seminar. 

Dr Jahangir Alam said that from the epidemiological study, it might be predicted that after the introduction of HPAI in Bangladesh the virus spread to waterfowl and initially the native chicken and ducks might have been infected after coming into contact with the migratory birds.

Then the virus would have spread to commercial farms through poultry workers, poultry feed and medicine suppliers, feed and egg carriers and egg trays.

Socio-economic analysis shows that the poultry industry of Bangladesh faced a financial loss in 2008 due to the second wave of bird flu attack, which was estimated at Tk 3,858.31 crore. The affected farms lost their business and many of them were reluctant to go back to the production system.

The study recommended promulgating an ordinance to control movement of migratory birds throughout the country, except in selected locations or sanctuaries. 

Early detection of HPAI virus, efficient surveillance and strict maintenance of bio-safety measures should also be ensured, it added. 

At the same time, it is important to share information and undertake studies on HPAI bilaterally and regionally to minimise the risk of sustained endemic of AI in poultry in the region. 

Source: The Daily Star, July 30, 2008 

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