The New Nation - Internet Edition

Hepatitis B: The silent killer

Mohammad Mazibur Rahman, MD

Hepatitis B is a more deadly disease than HIV/AIDS. In fact, this disease takes two lives every minute. Moreover, one out of three of the 6 billion people in this world are infected with Hepatitis B and around 400 million people of the entire planet earth carry the virus of Hepatitis B. Furthermore, the number of new cases of Hepatitis B is between 10 to 30 millions and number of death due to Hepatitis B and its complications is around one million each year. The infectious potential of Hepatitis B is hundred times stronger than HIV and both the diseases transmit almost in a similar way. In addition, the long-term effect of Hepatitis B is more severe amongst children and under aged people than adults. Even though Hepatitis B is more dangerous than HIV, the good news is that there is very effective vaccine available in the market to prevent it.

Hepatitis is a kind of inflammation of the Liver, which lies on the upper right quadrant of the belly under the ribcage. Hepatitis infection can be acute, duration of which is less than six months and chronic the duration of which is more then six months.

The liver can be infected mostly with virus and sometimes, bacteria, fungi and many other organisms and insults due to injury and medications. While Hepatitis B is a DNA virus, there are five other different types of virus such as A, C, D, E and G. In our country, in particular, Hepatitis A infection is the most common, which in turn, is due to poor sanitation and consumption of contaminated water.

Hepatitis B is very prevalent in the underdeveloped and developing countries like Sub Saharan Africa, most of the Asia, Pacific Islands and in certain areas of Alaska. Patients having repeated blood transfusion for severe bleeding or for treatment of severe anemia for different reasons and patients on hemodialysis due to kidney failure are also susceptible to Hepatitis B. Individuals involved in promiscuous sexual behavior, involved in sex between same gender, having multiple sexual partners and having sexual intercourse with someone carrying Hepatitis B virus are also in great risk to catch hepatitis B. Intravenous drug abuse, snoring cocaine causing nasal septal injury and perforation, sharing same syringe and needle by multiple drug abusers, using un-sterile syringe and needles to collect blood from patients are also important way Hepatitis B is transmitted.

Health worker are also at great risk of contacting Hepatitis B, possibly from accidental needle injury while collecting blood from patients and while inserting intravenous line for saline or infusing medication. Laboratory technician too can contact Hepatitis B due to accidental exposure to contaminated blood or body fluids during laboratory procedures. Hepatitis B can also transmit from the infected mother to her baby while in the mother's womb or during delivery. Staying in an area for more than six months where Hepatitis B is very common, residents of long-term care institutions like nursing homes, dorms, hostels are also at increase risk of accruing Hepatitis B. It takes around one to six months to develop symptoms of hepatitis after been exposing to the virus and that period is called incubation period. Symptoms of acute and chronic Hepatitis B differ from each other. Children and young kids usually does not manifest significant symptoms, but in some cases symptoms varies from very minimum to liver failure that leads to death. Acute Hepatitis B can be silent, especially in children and young adults. Symptoms vary from mild illness to fulminant liver failure. Malaise, fatigue, pruritus, headache, abdominal pain specially on the right upper quadrant, myalgias-muslce pain, arthralgias-joint pain, nausea, vomiting, anorexia, fever, yellow discoloration of the eyes and urine and fever are also common but nonspecific symptoms of Hepatitis B.

Chronic Hepatitis B runs an indolent course, sometimes for decades. Fatigue is a common symptom. The disease can be apparent and diagnosed in an advanced stage and can manifest symptoms of end stage liver disease, like liver cirrhosis and liver cancer. Other organs of the body like kidney, skin, bone marrow and blood vessels can be involved because of the Hepatitis B infection.

It is very important to see a doctor once some one experiences symptoms of Hepatitis B, otherwise it can end up in liver failure in a very short period of time. If there is a suspicion of acute Hepatitis B, patients blood should be tested for Hepatitis B surface antigen (HBSAg), Hepatitis B core IgM antigen, Hepatitis B e antigen and elevated liver enzymes, all of which can confirm acute Hepatitis B. Persistent presence of Hepatitis B surface antigen, presence of Hepatitis B core IgG antigen, Hepatitis B e antigen and elevated liver enzymes identifies chronic Hepatitis B infection. Liver biopsy usually not required for diagnosis, but it can tell you the degree of inflammation and fibrosis resulting from chronic Hepatitis B.

The clinical course of Hepatitis B infection depends on the age of the person infected. Ninety percent of the children infected with the virus before age five and five to ten percent of the adults develop chronic Hepatitis. From the one percent of the chronic carrier cleared of the virus each year, thirty percent develops liver cirrhosis. Five to ten percent of the chronic carrier may develop liver cancer with or without preceding cirrhosis and the risk of liver cancer can depends on the degree of viral replication.

Prevention is better than cure; this proverb is very much appropriate in case of Hepatitis B. There are very few options for effective medical treatment and it is very costly. The goal of treatment is to clear the Hepatitis B virus from the body, disappearance of Hepatitis B surface antigen and Hepatitis e antigen and appearance of antibodies against these two antigens, normalization of liver enzymes and architecture of the liver tissue. Medications like interferon Alfa 2a and 2b, Lamivudine, adefovir, Entecavir and Telbivudine, which are approved by Federal drug Administration of USA and needs to be used for 4-6 months for the treatment of Hepatitis B. These medications are effective only in 10 to 30 percent cases. If the liver disease turns to advanced stage, Liver transplantation is the only option, which is very costly and not readily available.

However there is good news. The best way to protect someone from Hepatitis B is prevention and vaccination plays a very pivotal role in this regard. Hepatitis B vaccine can be administered in two different ways. In the developed country, it is a routine part of childhood vaccination program.

The first dose is administered usually on day two or three after birth, second dose in 2 months and the third dose is administered after 6 months of the first dose. Glaxo SmithKline has Twinrix vaccine's second dose is given on day 7 and third dose between 21 to 30th day of the first dose and a booster dose after one year. In this system, no further booster is necessary in future unless there is poor immune status.

Blood should be screened properly for all kinds of hepatitis viruses before transfusion. Also, it is better to avoid transfusing blood of professional donors.

Refrain from using illicit nasal and intravenous drugs, sharing no needles, using sterile and disposable syringe and needles to collect blood, injecting medication through muscle and intravenously. Moreover, be extra careful while drawing blood or handling blood or body fluids of infected patients while working in the laboratory as technicians and make sure not recap needles after drawing blood or pushing injections.

In addition, Health care providers like dentists and surgeons must use sterile instruments. As an individual following healthy and clean life style, it is very important not to engage in sexual promiscuity, not having multiple sex partners, not adopting homosexual behaviors and having protected sex with condoms even with legal married partners, if the legal married partner happens to carry Hepatitis B virus.

Government and private media, healthcare facilities should launch a campaign to educate our people about the consequence of hepatitis B and the way of protection from it. Moreover government can take an initiative to make the hepatitis B vaccine accessible and affordable to our people and can incorporate it as a part of childhood vaccination. Furthermore, quite interestingly, if we understand and follow the religious teachings, we can protect ourselves from many deadly diseases like Hepatitis B, HIV/AIDS and many other sexually transmitted diseases.

Factors risking breast cancer

Bijan Lal Dev

Cancer develops when cells in a part of the body begin to grow out of control. Normal body cells grow, divide, and die in an orderly fashion. Because cancer cells continue to grow and divide, they are different from normal cells. Instead of dying, they outlive normal cells and continue to form new abnormal cells. Cancer cells develop because of damage to DNA. This substance is in every cell and directs all its activities. Most of the time when DNA becomes damaged the body is able to repair it. In cancer cells, the damaged DNA is not repaired. People can inherit damaged DNA, which accounts for inherited cancers. Many times though, a person's DNA becomes damaged by exposure to something in the environment, like smoking, radiation, effects of chemicals and infectious agents. Cancer may affect people at all ages, even fetuses, but risk for the more common varieties tends to increase with age. Cancer causes about 13% of all deaths across the world. In the developed countries, cancer is presently responsible for about 25% of all deaths. Breast cancer is the fifth most common cause of cancer death after lung cancer, stomach cancer, liver cancer and colon cancer worldwide.

Breast cancer is a cancer that starts in the tissues of the breast cancer, that is, the glandular breast tissue. There are two main types of breast cancer: 1) Ductal carcinoma starts in the tubes (ducts) that move milk from the breast to the nipple. Most breast cancers are of this type. 2) Lobular carcinoma starts in parts of the breast, called lobules, which produce milk. In rare cases, breast cancer can start in other areas of the breast. Many breast cancers are sensitive to the hormone estrogen. This means that estrogen causes the breast cancer tumor to grow. Such cancer is called estrogen receptor positive cancer.

Because the breast is composed of identical tissues in males and females, breast cancer also occurs in males, though it is less common. Women are 100 times more likely to get breast cancer than men. In 2005, breast cancer caused 502,000 deaths throughout the world. It is 7 per cent of cancer deaths and almost 1 per cent of all deaths. Among women worldwide, breast cancer is the most common cause of cancer death. Over the course of a lifetime, one in eight women will be diagnosed with breast cancer. In Bangladesh breast cancer causes death to over 22,000 women every year and out of them 15,000 die without any treatment.

Detection: Breast cancer screening is an attempt to detect unsuspected cancers. The most common screening methods are self and clinical breast exams, x-ray mammography, breast Magnetic Resonance Imaging (MRI), ultrasound, and genetic testing. Breast self-examination has been widely discussing since 1990s as a useful modality for detecting breast cancer at an earlier stage of presentation. Every women over 20 years of age should follow breast self-examination every month and clinical examination once a year. Changes in the appearance or shape of the breast can raise suspicions of breast cancer. Early breast cancer can in some cases present as breast pain or a painful lump. The women can be taught self-exam tended to detect breast nodules. Another reported symptom complex of breast cancer is Paget's disease of the breast. This syndrome presents as eczematoid skin changes at the nipple, and is a late manifestation of an underlying breast cancer. Self-examination has chances to ignore even the definite cancer symptoms. So, mammography is still the modality of choice for screening of early breast cancer, since it is relatively fast, reasonably accurate, and widely available in most of the countries. Breast cancers detected by mammography are usually at earlier stage than those detected by patients or doctors as a breast lump. Annual mammography of women older than age 40 or 50 is recommended by numerous organizations as a screening method to diagnose early breast cancer and has demonstrated a protective effect in multiple clinical trials. Mammography has been estimated to reduce breast cancer-related mortality by 20-30%. Women with one or more first-degree relatives (mother, sister, and daughter) with pre-menopausal breast cancer should begin screening at an earlier age. It is usually suggested to start screening at an age that is 10 years less than the age at which the relative was diagnosed with breast cancer. The breast cancer is best diagnosed by the examination of surgically removed breast tissue. Occasionally, breast cancer presents as metastatic disease, that is, cancer that has spread beyond the original organ. Metastatic breast cancer will cause symptoms that depend on the location of metastasis. More common sites of metastasis include bone, liver, lung, and brain. The detection of such cancers is very difficult.

Factors risking breast cancer: There are some risk factors for developing breast cancer that you cannot change. These are: 1) Age and gender - Your risk of developing breast cancer increases as you get older. The majority of advanced breast cancer cases are found in women over age 50. 2) Family history of breast cancer - You may also have a higher risk for breast cancer if you have a close relative has had breast, uterine, ovarian, or colon cancer. About 20-30% of women with breast cancer have a family history of the disease. 3) Genes - Some people have genes that make them more prone to developing breast cancer. These genes normally produce proteins that protect you from cancer. But if a parent passes you a defective gene, you have an increased risk for breast cancer. Women with one of these defects have up to an 80% chance of getting breast cancer sometime during their life. 4) Menstrual cycle - Women who get their periods early (before age 12) or went through menopause late (after age 55) have an increased risk for breast cancer.

According to the US National Cancer Institute, there are other risk factors which can be changed. These include: 1) Alcohol use - Drinking more than 1-2 glasses of alcohol a day may increase your risk for breast cancer. 2) Childbirth - Women who have never had children or who had them only after age 30 have an increased risk for breast cancer. Being pregnant more than once or becoming pregnant at an early age reduces your risk of breast cancer. 3) Obesity - Obesity has been linked to breast cancer, although this link is controversial. The theory is that obese women produce more estrogen, which can fuel the development of breast cancer. 4) Radiation - If you received radiation therapy as a child or young adult to treat cancer of the chest area, you have a significantly higher risk for developing breast cancer. The younger you started such radiation, the higher your risk - especially if the radiation was given when a female was developing breasts. Besides, hormone replacement therapy for several years to reduce the symptoms of menopause and using diethylstilbestrol for preventing miscarriage may have an increased risk of breast cancer after age 40.

Treatment: Breast cancer behaves very differently. It grows at different rate and responds to different treatments. It may be one of the oldest known forms of cancer tumors in humans. The oldest description of cancer (although the term cancer was not used) was discovered in Egypt and dates back to approximately 1600 BC. "There is no treatment." For centuries, physicians described similar cases in their practices, with the same sad conclusion. It was William Stewart Halsted who started performing mastectomies that is, removing the lymph nodes, breast tissue, and underlying chest muscle through a surgical procedure in 1882. It was remained popular for breast cancer treatment up to the 1970s. Till the mainstay of breast cancer treatment is surgery when the tumor is localized, with possible adjuvant hormonal therapy, chemotherapy, and/or radiotherapy. Depending on clinical criteria (age, type of cancer, size, metastasis) patients are roughly divided to high risk and low risk cases, with each risk category following different rules for therapy. Treatment possibilities include radiation therapy, chemotherapy, hormone therapy, and immune therapy in addition to surgery.

Prevention: Plant estrogen intake, such as from soy products, in early adolescence may protect against breast cancer later in life. Studies have found that foliate intake counteracts breast cancer risk associated with alcohol consumption and "women who drink alcohol and have a high foliate intake are not at increased risk of cancer. Foliate is involved in the synthesis, repair, and functioning of DNA. Foods rich in foliate include citrus fruits, citrus juices, dark green leafy vegetables (such as spinach), dried beans, and peas. Vitamin B9 can also be taken in a multivitamin pill. Removal of ovaries, in high-risk individuals, when child-bearing is complete, reduces the risk of developing breast cancer by 60%, as well as reducing the risk of developing ovarian cancer by 96%. Fatty diet, obesity and alcohol consumption are major reasons of breast cancer while physical exercise and early detection can prevent the fatal disease.

Conclusion: Early detection of breast cancer is the only way to live long and may eliminate death risks in many cases. There are medicines now for treating breast cancer and cure rate is now 90 percent if you detect early. But ignorance, innocence, negligence and shyness make the women prey of breast cancer. Even educated and urban women show reluctance to follow the health care rules. So, building massive awareness is the best way to prevent breast cancer.

There are many ways in creating awareness but media could play the dominant role at this end. Over 68 per cent of the breast cancer mortalities in Bangladesh die without any treatment. Both print and electronic media can play a significant role by elaborating the risk factors, symptoms, detection means, and treatment and prevention methodologies. We should inspire the womenfolk of the country to learn and follow the detection and treatment procedures of breast cancer and know how to prevent this deadly disease.

Medicine at our door steps: Tea

Jamayet Ali

Tea is a variable evergreen bushy shrub or small tree with leathery deep green leaves and fragrant white flowers, cultivated commercially for the production of tea in Sylhet, Moulvibazar, Chittagong and Chittagong Hill Tracts of Bangladesh. The main tea growing countries of the world namely China, India and Srilanka lie within a restricted geographical region in Asia. Indonesia, Turkey, Bangladesh, Kenya and Russia also produce sizeable quantities of tea. It is also cultivated in Malawi, Argentina, Iran, Japan and in some other countries. The harvestable area under tea in the world in 1986 was 2537 thousand hectares, 93.9 percent of which exists in the developing countries. Within Asia, the maxium area under tea is in China with about 1,174 thousand hectares which accounts for 532 % of Asia's harvestable tea area and 46.2 % of the world's. India ranks second with about 400 thousand hectares (18.1 % of harvest able tea area in Asia and 15.7 % of the world's area under tea), whereas Sri Lanka harvested from about 252 thousand hectares (11.4 % of share of tea area in Asia and 9.9 % of world's tea are) in 1986.

Tea is today the most widely used and popular non alcoholic beverage and large quantities are consumed daily by millions of people in all parts of the world. About half the world's population drinks tea regularly and it is the commonest beverage in Asia and the Far East. The word tea comes from a Chinese indiogram pronounced 'Tay' in Amoy dialect and came into English with the pronunciation changing to its present form in the 18th century. In Cantonese it is known as ehah a name which came into use in India and Russia. China was the first country to cultivate tea. Tea as a beverage, produced by steeping processed top leaves and buds of the tea plants in freshly boiled water originated in China c2700 BC; but the tea leaf has probably been in use as a medicine much longer than that Tea cultivation of the tea plant in Japan began about 200 AD. The use of tea later spread to the other Asian countries. Tea cultivation in sub-continent began as early as 1778. The tea plants growing wild in Upper Assam was discovered in 1823. In Java, commercial production of tea began in 1824. Extensive planting began in Srilanka in the 1870's. Tea as a beverage was introduced to Europe in 1610 AD by the Dutch and by the first half of 18th century tea was a popular beverage in Holland, England and the American continent. Several types of commercial teas are known such" as black, green, oolong, brick and let-pet teas. Each of these teas has its own characteristic aroma and taste.

Medicinal Properties: Tea is a stimulating drink. It relieves muscular and mental fatigue and is taken for fever. The stimulating action is attributed to the purine base alkaloid, caffeine present to an extent of 1-5 per cent in black tea, 80 per cent of which is extracted during normal brewing. An average consumption of 5-6 cups per day represents a caffeine intake of about 0.3g, which is less than half the daily 'tolerable limit' of 0.65g for the medical administration of pure caffeine. Caffeine has a diuretic effect on the kidneys and stimulates gastric secretion. Hence, tea is thought to aid digestion and relieve post prandial distress. Excessive doses of caffeine, however, can lead to anxiety and unpleasant gastric sensation. Tea has also been claimed to have beneficial effect on numerous other diseases and conditions. Tea may be of value in treatment of gout and restoration fluid balance following vomiting and diarrhoea.

The diuretic property of tea is useful in therapy of cardiac odema. It seems to reduce serum lipid, induce synthesis and secretion of catecholamines and to prevent atherosclerosis. Tea polyphenols may inhibit the absorption of dietary cholesterol and prevent the degradation of catecholamines. There is indication that successive administration of tea could stimulate the degradation of triglycerides in the adipose tissue, thereby reducing the weight. Tea may be used in relieving bronchial asthma and difficulty in breathing due to the smooth muscle relaxant effect of caffeine. Tea polyphenols strengthen the walls of blood vessels and regulate their permeability, an activity associated with o-dihydroxybenzene group collectively termed vitamin P or biflavonoids.

Tea polyphenols protect ascoroic acid from oxidation in rat tissue homogenates because of their antioxidant properties. Tea extracts increase the accumulation of ascorbic acid in rat and guinea-pig tissues and reduce the level of ascoroic acid through urinary excretion. It indicates an important role of green tea in human nutrition in preventing symptoms of ascorbic acid deficiency. Green tea polyphenols have been found to normalise thyroid hyperfunction which induces thyrotoxicosis; this has been attributed to flavanols, especially galocatechins. Flavonol glycosides exihibit a similar action. tea was used extensively in combating plague in Japan. Green tea infusion shows anti-bacterial activity against a number of bacteria and is an effective cure against dysentery. Without milk and sugar the tea liquor is beneficial in diarrhoea but with milk and sugar it acts as a laxative.

Green tea inhibits the growth of cancer tumours. Tea affords protection against the development of leukemia after exposure to radiation in mice. Epigallocatech in gallate (EGCG) from green tea changes the properties of the receptor on the surface of mouse eland blocks the section of tumour promoter and thus prevents the formation of ur cells. EGCG might also prevent the growth of tumours in humans especially cancers of oesophagus, stomach and intestines. High selenium content in teas has been correlated with low incidence of cancer in Japan. Green tea is best in preventing the synthesis of the carcinogen, followed by black and jasmine teas.

Green tea extract has been reported to be more effective in preventing tooth decay than fluoride compounds. An extract of Japanese green tea inhibited the growth of streptococcus mutans Clarke, the cariogenic bacterium responsible for causing dental caries. Tea is considered a cure for cold and removes phlezm. It prevents the formation of stones in bladder, liver and kidney. Tea can be used as a base for the extraction of catechin, the preparations of which are useful in treating nephritis and chronic hepatitis. The bitter leaf juice is taken for abortion. Dried leaves are chewed to remove foul smell. The leaf juice is also applied to cuts and injuries as haemostatic. Tea has also been successfully used in treating severe abdominal , intestinal and cerebral haemorrhages. Green tea tannin or its active constituents may be used in treating toxic goiter.

The extract of Japanese Green tea shows anti-hepatoxic effects. Tea has been found to aid liver, lessen tissue waste, promote cerebration, aid mental arid physical work, preserve mental equilibrium, induce tranquility and promote slenderness. Tea inhibits absorption of iron and leads to iron deficiency. Polyphenolic compounds in tea which forms strong complexes with iron are believed to be partly responsible. Tannase, a polyphenol degrading enzyme, and lemon juice solubilise iron and also calsium in some teas and, therefore, might reduce detrimental effect of tea on mineral availability. On the other hand, these observations have promoted research into a possible therapeutic use of tea for individuals who suffer from iron over load from excessive absorption (Wealth of India, Raw Materials, Vo 1. III ).

Medicine: Tea is useful in treating infections of the digestive tract. Leaves are excellent CNS stuimulant, diuretic and astringent. They possess antimicrobial activity against microorganisms causing intestinal disorders. Lyophilised aqueous extract of leaf, stem and twigs is useful in cosmetic and dermo-pharmaceutical beauty products. Pharmaceuticals containing tea extract and other ingredients are useful against tumours, diabetes and arthritis. Caffeine is extensively used in modem medicine in the treatment of migraine, hemicrania, neuralgia and other nervous affection and as a stimulating hot drink. Theaflavin extracted from leaves is an effective antibacterial agent. The saponins of tea leaves produce anti-hypertensive rats (Medicinal Plants of Bangladesh, Second Edition, 143-44).