The bacteria that causes meningococcal meningitis sometimes results in an overwhelming infection in the blood which can quickly kill. When it results only in meningitis it is the least serious and easiest to treat of all bacterial meningitis in children.

How Sick Will You Be?

Most children who are exposed to meningococcal bacteria meningitis do not become ill.
Before improved antibiotics and intensive medical care, about half the people with meningococcal meningitis died. Now, almost all recover, except those with fulminant bloodstream disease. This is difficult to treat because bacteria multiply and spread so quickly throughout the bloodstream. The antibiotics can’t attack such high numbers of bacteria fast enough to prevent death. About 10 to 12 percent of victims die, despite antibiotic treatment.

Incubation Period

The incubation period is usually about a week.

Infectiousness

Children with diagnosed meningitis are infectious until they have received 24 hours of antibiotics. Your child will be placed in an isolation room and staff and parents will need to wear masks over their noses and mouths for this time. Before leaving the hospital, the child will receive rifampin to make sure he no longer carries the bacteria in his throat. The child can return to child care or school as soon as he feels well enough.

Healthy children who carry the bacteria in their noses and throats are infectious for a few weeks to a few months.

Immunity

You become immune to the specific group of bacteria causing the infection. Complications
If bacteria invades the blood as well as the meninges, it can lead to arthritis, heart infections, and pneumonia. It may damage the nerves leading into the brain, causing long-term complications such as hearing loss or mental retardation. These complications occur much less often after meningococcal meningitis than after other types of bacterial meningitis.

How Do You Cure It?

Penicillin G every four to six hours for five to seven days is the usual choice. The child may receive two antibiotics until the doctors know which kind of meningitis your child has. However, either the rash or rapid tests may reveal the diagnosis of meningococcal meningitis right away.

Nursing Care

Most children with meningitis are bothered by bright lights and noise, so the room is quiet and the lights as low as possible. Once the child has regained full consciousness, the nurse will give fluids and then move the child to a normal diet.

At home treat any fever higher than 101°F (38.3°C) with acetaminophen (not aspirin), and sponge the child down with lukewarm water. See treatment for fevers in chapter 2.
Stay calm. Sick children need to be reassured, not scared, by their parents. Ask for and expect full and clear explanations from the doctors in the emergency room nd hospital about everything they are doing to your child. Meningitis can be difficult to diagnose, and the doctors will not know right away if your child has meningitis, or if he does, what kind it is. Test results are not always clear or easy to interpret. If you have given your child oral antibiotics recently, the test results will be even less reliable.

After recovery, take your baby or child for a hearing test and then periodically for the next 12 months.

How Do You Prevent It?

This disease cannot always be prevented because the bacteria is so commonly found in healthy mouths. Researchers are now testing vaccines that work in young children. Until then, the best strategy is to teach good hygienic practices to children who attend child care and to those who live away from home in group settings, to give rifampin to exposed close contacts, and to vaccinate in cases when the strain is susceptible to vaccine.

The doctor must report meningococcal meningitis to the health department. Inform your child’s school or child-care center of the diagnosis. This should be written out by the doctor or nurse caring for your child. The school nurse or center director must know exactly what kind of meningitis your child has in order to decide what, if any, measures they must take to protect other children.
Concerned parents should carefully watch their exposed children over the next two weeks for any signs of illness. If a friend or classmate comes down with fever, parents should promptly notify the doctor and have the child examined, being sure to tell the doctor that the child was exposed to meningococcal meningitis. In this situation, doctors should have what is called a high index of suspicion for meningococcal meningitis.

Vaccines and Postexposure Prevention

Household members, close friends at school and home, and, if the child attends child care, all preschool children who are cared for in the same room should receive rifampin (see page 204) as soon as possible, preferably within 24 hours of the diagnosis. Anyone who. has had such close contact as kissing or sharing drinks, food, or utensils with the patient also needs rifampin, which is available only by prescription.

Other effective preventive antibiotics for contacts are ceftriaxone and ciprofloxacin.
The only available vaccine is effective against groups A, C, Y, and W-135, but not group B. It doesn’t work well in children younger than two. It takes one to two weeks to develop immunity after immunization. For that reason, the vaccine is not helpful in protecting other children when one child in a group has already come down with the disease. If an exposed child is going to develop meningitis, it usually happens within one week. However, one study did show that giving vaccine and rifampin to a group of exposed children seemed to reduce the number who later came down with meningitis. But if group В is causing the disease, this vaccine does no good at all.

The vaccine is recommended for:

■ Military recruits
■ Children without spleens
■ Travelers to areas with epidemics of group A or С meningitis
■ Exposed groups in areas where an epidemic is occurring and the cases are due to groups A, C, W-135, or Y

The vaccine is available from local distributors or Connaught Laboratories at (800) VACCINE.
A mass immunization program costing more than $6 million took place in January 1992 in the Canadian provinces of Quebec, Ontario, and Prince Edward Island after 11 seemingly healthy teenagers died from meningococcal meningitis group C. More than 427,000 residents were vaccinated, ranging in age from 6 months to 29 years. The company that makes the vaccine said it was the largest demand ever for the vaccine in an industrialized country. Some experts questioned the need for such a mass immunization in a situation that was not considered an epidemic. However, because the death rate was so high and panic verging on hysteria was taking place among parents and children in the affected communities, the public health authorities went ahead. All of the close contacts also received rifampin.

Enteroviruses are the usual cause. These are viruses that only infect humans and are spread by the fecal-oral route. They live in the human intestine. Echovirus and Coxsackie are two that cause most viral meningitis in the United States. Polio is also an enterovirus. Sometimes the others are called nonpolio enteroviruses.

Viral meningitis is fairly common and a relatively mild illness, when compared to most bacterial meningitis. Some doctors call it aseptic meningitis because bacteria do not grow in the spinal fluid. Because doctors know the patient has meningitis but don’t know the cause, they say it is aseptic. I think this is a confusing term because a virus has invaded the spinal fluid and it is not sterile, as the name implies.

Viral meningitis is spread by direct contact with infected feces or nose and throat secretions. Most children carry the virus without becoming ill. It spreads most easily among young children and in any group-living situation where sinks and running water are in short supply. It usually strikes young children in the summer and early autumn. Anyone can get the disease, but most people over 40 are immune.

No one knows why only a few children who are exposed to these viruses become ill, or why some get meningitis. It likely has something to do with each individual immune system, much of which is genetic. Children and adults who are well fed and well rested and live in adequate conditions will be less likely to come down with these infections.

How Do You Know If You Have It?

Usually viral meningitis starts suddenly. Babies may have a more gradual illness—refusal to eat, sleepier than usual, fussy. Babies younger than 18 months may develop a rigid or tender back or neck and extreme fussiness that cannot be consoled. Bulging fontanelle (soft spot) occurs less in viral meningitis and if it does, it’s usually a late sign.

Some viral meningitis results in a rash that may cover most of the body or jusi the arms and legs. The rash is red and flat, although it may be raised in some areas. It is not the same as the rash in meningococcal meningitis, which is small, with pinpoint bright red spots covering most of the body.
Enterovirus meningitis may also cause a sore throat and conjunctivitis.

Tests

If no bacteria grow on the culture plate after 72 hours, and all the other tests that look for bacteria find nothing, the diagnosis will likely be viral meningitis. If the doctor suspects viral meningitis, your child will need fecal, respiratory, and nose cultures because the virus is often found in these areas.

How Sick Will You Be?

Most children and adults recover completely within 10 to 14 days. A few children have a long convalescence from viral meningitis. They may have muscle weakness, tiredness, headache, muscle spasms, insomnia, or personality changes such as behavioral problems and inability to concentrate. These are rarely permanent, but may take a few weeks to a few months to disappear.

Incubation Period and Immunity

Incubation and immunity are poorly understood and vary with each virus.

Infectiousness

Healthy carriers or sick children carry the virus in their feces before they become ill and for weeks after recovery.

Complications

Increased pressure on the brain from a buildup of fluid in the meninges is a serious complication. See Bacterial meningitis.

Some infants with early meningitis have delayed language development. If your baby younger than six months has a bout of viral meningitis and you have any concerns about his speech development, take him for a picture vocabulary test after age three. If you catch this problem early, you can get help to ensure that your child will not be behind when he starts school.

People with weakened immune systems may have chronic infection with enterovirus.

How Do You Treat It?

There is no medicine for viral meningitis. The immune system will develop antibodies to destroy the virus.

Until it is known that your child has viral, not bacterial meningitis, she will be admitted to the hospital. But once the diagnosis is made, antibiotics are stopped, and a child who is recovering nicely will be sent home.

Nursing Care

Give only acetaminophen to reduce fevers. Offer clear fluids and a bland diet including favorite foods. During recovery, your child needs rest in a darkened, quiet room. Bright lights, noise, and visitors may irritate a child with meningitis.

Take your child for a hearing test and muscular assessment several weeks after recovery.

How Do You Prevent It?

No vaccine or preventive medicine is available. The only prevention, especially for young children attending child-care centers or day camp, is hand washing after using the toilet and blowing noses, and before eating.

How Do You Get It?

The bacteria gets into the body through the nose. The disease occurs when bacteria escape the respiratory tract and travel through the bloodstream to the meninges.

Healthy people who carry the bacteria in their nose and throat secretions are the cause of most meningitis. These carriers spread the infection to others through a cough, sneeze, or direct oral contact—kissing or sharing drinks, food, utensils, or handkerchiefs. Fortunately, meningitis spreads slowly, and most people don’t get sick. More boys get meningitis than girls.

How Do You Know If Your Child Has It?

Bacterial meningitis can come on suddenly or gradually in children. The gradual type (which is less common) is harder to diagnose, because the symptoms are often similar to other mild illnesses in children—fever, lethargy, vomiting, refusal to eat, or cold symptoms.

Meningitis usually develops in less than 24 hours. When it attacks suddenly it’s easier to diagnose, but often signals a sicker child. The young child may have a sudden fever, chills, vomiting, stiff neck, or a seizure. Commonly, the child is extremely irritable, screams, and becomes delirious and agitated. Or she may be extremely lethargic and even fall into a stupor or coma.

Babies from three months to two years old may have fever, vomiting, irritability, seizures, and a high-pitched cry, and sometimes become rigid. Usually you’ll see that the fontanelle, or soft spot, on the baby’s head is bulging.

Some children have colds or ear infections before meningitis comes on; others don’t. Any sudden change in consciousness or inexplicable behavior in a young child may be a sign of meningitis. Call your doctor immediately if you notice any symptoms that might suggest meningitis.

Tests

Many tests are done on a baby or child with possible meningitis. A lumbar puncture (LP, or spinal tap) must be done whenever there is a possibility of meningitis. This procedure is used to get a sample of fluid from around the spinal cord, called cerebrospinal fluid (CSF). The doctor will check the CSF for appearance, white blood cells, sugar, and protein. It is examined on a slide in the lab and also sent for culture. The results are important in determining what type of germ is causing the meningitis and what medicines the child needs.

In bacterial meningitis the fluid looks cloudy, numbers of certain types of white blood cells are high, protein is high, and sugar is low. The results must be interpreted taking into account the child’s physical condition and all the other results.

Bacteria will grow in blood or CSF in 24 to 48 hours. Rapid tests on urine or blood give results in a few hours and are often helpful in identifying which bacterium is causing the meningitis. Sometimes the organism is identified by placing a drop of either CSF or blood on a glass slide, staining it, and examining it under a microscope.

Some parents fear lumbar puncture and question the need for it or even refuse permission. But it is the only way to accurately diagnose or rule out meningitis. It is a safe procedure when done in a large hospital emergency room or in an experienced pediatrician’s office.

Complications

Increased pressure on the brain from a buildup of fluid in the meninges is a serious complication. The nurses will closely watch for any signs of this—change in head measurement from day to day, any change in activity or responsiveness, vision changes, changes in pupils’ response to light, changes in breathing, or decrease in urine.

The most common long-lasting complication is hearing impairment. Recent studies demonstrated that H. flu meningitis victims who received a steroid called dex-amethasone right away had less hearing loss than children who did not. It is not clear from the limited studies whether dexamethasone benefits children with other kinds of bacterial meningitis. Take your baby or child for a hearing test after recovery and periodically for the next 12 months.

Other less common complications are hydrocephalus, blindness, arthritis, seizures, and permanent developmental or learning delays. Many developmentally delayed children are survivors of bacterial meningitis.

How Do You Prevent It?

A prescription antibiotic called rifampin is used to prevent cases of Hib and meningococcal meningitis after exposure. This prescription antibiotic must be prescribed and administered under a doctor’s supervision. It is given to all children younger than two years old in a child-care center, adult staff in the center, and family members of the sick child if the household includes other children younger than four years old. Rifampin will temporarily get rid of H. flu and meningococcus from the noses and throats of healthy carriers about 95 percent of the time. It helps prevent any exposed child in the center or family from getting meningitis.

Rifampin is taken by mouth once a day for four days in a dosage that depends on the child’s weight. Rifampin turns urine, tears, and saliva an orange color, causes some nausea and vomiting, cannot be given to pregnant women or anyone with liver disease, and is expensive.

Until a few years ago, most young people had never seen anyone with measles. Doctors thought they had conquered this ancient, deadly disease, but they were wrong. When the measles vaccine was licensed in 1963, public health officials figured measles would be eliminated by 1982. This failed to happen, so the target date for measles elimination was revised to 1990. Instead, measles cases in the United States began to rise from only 1,500 cases in 1983 to 28,000 reported cases—about half in children younger than five years old—in 1990. Many high schools and colleges had measles outbreaks in the late 1980s and early 1990s. As a result, athletic events were canceled and classes were disrupted. Most high schools and colleges now require students to be re-immunized. Since 1991, measles is again on the decline.

Rhazes, a tenth century Persian physician, first described measles that he called in Arabic, hasba. This disease spread across North Africa and into Europe. Measles killed thousands of New World Indians when Spanish explorers infected them in 1517. The Spaniards called it pequena, the little leprosy.
Scientists discovered in 1911 that measles is caused by a virus. It wasn’t until 1954 that two Harvard researchers were able to isolate the actual measles virus in the laboratory. They then began to search for a vaccine to prevent it.

How Do You Get It?

Measles is one of the most highly contagious diseases known. It is an airborne disease* that is spread simply by breathing in air that contains the measles virus. When a measles victim breathes, coughs, sneezes, or talks, the virus is released into the air. These virus particles travel through the air suspended in small droplets and can infect people who are nowhere near the person who has measles. In one hour, over 5,000 virus particles will be breathed into the air by someone with measles. These virus particles can remain in the room for almost two hours.

The virus survives best in rooms with low humidity. If you enter a room as long as two hours after someone with measles has left, you can still catch measles from that person. In several hospitals, including the one where I worked, children caught measles from other sick children whose rooms were at the other end of the hall because the measles virus traveled down the hallway and into their room. Indirect contact such as touching the bedding or towels of the infected person will also give you measles.

Direct contact with the secretions from the infected person’s runny nose, eyes, or cough can also spread the disease. If these secretions get on your hands and you touch your eyes, nose, or mouth, you will infect yourself.

There is a milder form of the illness, which occurs in people who are not able to develop adequate immunity from just one dose of vaccine. These people can get measles as their immunity begins to wear off. We don’t know why this happens. They may have low fevers and rashes that appear only on their faces or trunks.

In September 1991, three female teenage gymnasts from New Zealand came down with this milder form of measles while taking part in an international competi-tion in Indiana. Hundreds of athletes, coaches, and 60,000 spectators from 51 countries were at risk of exposure from these three athletes. Officials acted quickly and vaccinated more than 1,100 participants within three days.

Babies will have some immunity to measles when they are born if their mother was immune, either through a vaccine or by having had measles herself. This “maternal immunity” lasts about six months.

How Do You Know If You Have It?

The first signs of measles will appear about ten days after the virus enters your body. This ten days is the incubation period. You will get a fever, as high as 105°F (40.6°C), and a general sick feeling. The next day you will develop a cough; red, puffy, painful eyes (conjunctivitis); a runny, stuffed-up, congested nose (coryza); and a cough. You may only get one or two of these other symptoms, but you will always get the fever, which will last for about six days.

Tests

Doctors usually diagnose measles by symptoms. However, blood tests that look for antibodies to the measles virus are available in large commercial and state labs. Large hospital labs can do rapid tests to detect antibodies in throat specimens and can also grow the measles virus in culture.

How Sick Will You Be?

Everyone who gets measles is miserable, but babies and adults are usually the most seriously ill. Measles is a serious illness. I saw many hospitalized babies and toddlers sick with measles in the winter of 1990 to 1991. They all had the same miserable “measles look.” Children with measles are much sicker than they are with a simple cold or flu or chicken pox.

On the second day of the fever, Koplik’s spots, which are tiny white spots on a red base inside the mouth, will appear. You may not be able to see these spots in your child’s mouth, and they will disappear in a few days. Four days into the fever, all of these symptoms will be worse, and the measles victim will get a rash that usually starts on the face, especially the forehead. It will then spread downward and outward. It will be a bright red, raised, blotchy rash that tends to run together. It is easily seen on all complexions. The rash will probably spread all the way down to the feet in three days, and then will start to fade. Altogether, the rash lasts about six days.

Your child’s fever will begin to fall on the second day of the rash. The runny, congested nose and red eyes usually clear up as the fever falls and the rash fades. The cough, however, can last a long time. Your child may cough for as long as two weeks.

Incubation Period

The incubation period is usually 10 days to the fever and 14 days to the rash, but this can range from 8 to 18 days to the fever. This means that 10 days after you are exposed to measles and the virus enters your body, you will develop symptoms.

Infectiousness

You are infectious from just before the fever begins to the fifth day after the rash appears. The most infectious time is the period before the rash begins. You may not know that you have measles at this time, but you can give it to other people. This period between the first sign of illness and the appearance of the rash is called the prodromal period.

Anyone in the infectious stage of measles must stay away from school and work. If your child has any of the symptoms of measles without the rash, especially the high fever, she should not be sent to school, child care, or any place where there are other children.

Immunity

You can catch measles only once in your life. Before the vaccine, almost everyone got measles as a child. Once you have had the measles infection, your body will develop lifelong immunity. You will have antibodies in your blood that will destroy the measles virus if it tries to enter your body. The vaccine also gives you lifelong immunity to measles. If you receive two doses of the vaccine at the right ages, you will not get measles.

Complications

Babies will get dehydrated more quickly, are more likely to have diarrhea and vomiting, and often are struck with middle-ear infections. A child who develops measles pneumonia may require oxygen or mechanical ventilation to assist breathing. Measles encephalitis, a rare complication, can lead to death or permanent brain damage. Adults can also suffer from very high fevers and dehydration.
Small babies, older people, and people with other serious health problems often get severely ill or even die from measles because their body’s immune systems are unable to develop enough antibodies to destroy the measles virus, and the virus wins the battle. These people may die even if taken to the hospital. Measles is a common cause of death and blindness among malnourished children in developing countries because they have weakened immune systems and cannot fight the infection.

How Do You Treat It?

There is no medicine to cure measles. The disease is going to take its natural course, and the body’s defenses will eventually get rid of it by developing antibodies that destroy the measles virus.
Treatment is symptomatic, that is, doing things that will make your child feel better. A child with measles requires good nursing care and is best cared for at home in familiar surroundings. A parent, reliable babysitter, or friend can provide care. Be sure the caregiver is familiar with the symptoms of the illness and what danger signals to watch for.

Nursing Care

For fever higher than 101°F (38.3°C), give acetaminophen (Tylenol) every four hours. Offer the child plenty of clear fluids to prevent dehydration. Give small sips to prevent vomiting.
Your child needs plenty of rest, so provide quiet activity. Keep the room dark, as bright light may bother your child’s eyes. To soothe itchy, watery eyes, wipe them gently with a warm washcloth. Ease the cough with a cool-mist vaporizer.

Call the doctor immediately for these signs:

■ Vomiting all liquids
■ Signs of dehydration
■ Wheezing or trouble breathing, which may be a sign of measles pneumonia, caused by the spread of the measles virus to the lungs
■ Fever that last more than four days after the rash appears or a fever that goes away and then returns, which may signal the beginning of a secondary bacterial infection
■ Unusual drowsiness, extreme fussiness, stiff neck, or inability to be consoled, which may be signs of measles encephalitis caused by the spread of measles virus to the brain
■ Ear pain, or pulling at the ears, which may be a sign of a middle-ear infection

How Do You Prevent It?

Measles is a completely preventable disease. Two doses of measles vaccine are now needed for complete protection. The first dose should be given to all babies after 12 months and not later than 15 months of age. About 95 percent of people will be protected after this first dose. The booster, which is now recommended at 4 to 6 years old, or at 10 to 12 years, will protect 95 percent of those who may have failed to become immune after their first vaccine dose. Then, 99 percent of the population will be immune. This will leave such a small number of nonimmune people that measles will no longer be a problem. Herd immunity will protect these people. This means that because almost everyone in the population is immune to measles, its spread will be blocked to those few who are not.

In areas where there is a measles epidemic, three doses of vaccine are needed. The first dose is given at 6 months, a booster at 15 months, and a second booster at 4 to 6 years of age.

Measles killed 89 people, more than half of whom were children, in the United States in 1990. In the winter of 1991, nine children in Philadelphia alone died from measles. Two children with weakened immune systems died from measles in the children’s hospital where I worked, despite aggressive intensive medical care.

Measles is again on the decline. In the United States, cases dropped to just under 10,000 in 1991, and to 700 in 1994. Before the vaccine, measles epidemics came in two- to three-year cycles. Public health officials think this may explain the dramatic drop in measles in the United States in 1992 to 1993. Immunization rates among preschool children have improved, but many young children are still not being vaccinated. A few small outbreaks occurred in spring of 1994- Measles will reappear unless all children receive the measles vaccine on time.

Now we understand why the late medical historian Dr. Samuel Radbill wrote that the “measles demon may always be lurking … in some unknown reservoir, ready to strike again at the first opportunity.”

How Do You Get It?

You get malaria in tropical or subtropical areas from parasite-infected Anopheles mosquitoes. The mosquitoes bite only at night.

The parasite produces larvae in the female mosquito’s intestines, which are discharged in the mosquito’s saliva and get into your blood when a female bites you. The larvae travel through your blood to the liver, where they invade the cells, develop and rupture after one to four weeks, spewing hundreds of matured parasites into your bloodstream. Symptoms begin at this point.

The matured parasites stay in the blood and do not re-invade the liver. Sometimes, a few stay in the liver in a dormant form and are released months to years later, causing relapses of malaria in people who thought they were cured.

Malaria is not passed directly from person to person, but infected people can give it to mosquitoes who can then give it to other people. Blood transfusion spread is also possible. All blood donors are carefully screened by questionnaire for possible exposure to malaria. IV drug users spread the disease by sharing dirty needles.

You might wonder why you can get malaria but not AIDS from mosquitoes. The answer is that the mosquitoes become infected with the parasite that causes malaria, but mosquitoes who bite HIV-infected people do not become infected with or carry HIV, the virus that causes AIDS. You cannot catch HIV or AIDS from a mosquito.

In 1945, 62,000 malaria cases occurred in the United States. Eradication efforts by the CDC reduced the number to a mere 61 cases by 1961, and many of these were imported from other countries. In the last ten years, however, an average of 1,200 malaria cases in civilians have been reported every year in the United States. Most are in people who were infected in other countries—either travelers or immigrants. A few cases are caught right in the United States, usually in California and Florida. In those states, mosquitoes that bite migrant farm workers who have untreated malaria become infected, then bite and infect other people.

Malaria exists in areas of Central and South America, Hispaniola, Africa, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania. The disease infects 300 to 500 million people every year and kills about 2 million people. Ninety percent of the cases and at least half the deaths are in sub-Saharan Africa. Eight thousand Brazilians die of malaria every year, more than from AIDS and cholera combined. And in 1992, 10,000 cases were diagnosed in Europe. U.S. military personnel who serve overseas must be constantly on guard against malaria. Many members of the armed forces who served in Somalia in 1992 to 1993 were found to be sick with malaria when they returned to the United States.

Malaria is a risk for international travelers. Your risk depends on what you do and where you go. Eighty percent of the 1,534 cases of serious falciparum malaria in American civilians that were reported to CDC from 1980 to 1988 were caught in sub-Saharan Africa. Travelers to Asia and South America are at less risk, but the risk is still significant. In 1990, 21 percent of all malaria cases reported in American travelers were caught in India. In 1992, five people died from malaria caught abroad; two of these contracted the disease in India.

Travelers who stay in air-conditioned hotels on tourist itineraries in urban or resort areas are at lower risk than backpackers, missionaries, and Peace Corps volunteers.

How Do You Know If You Have It?

Symptoms vary, but most people have fever, chills, sweats, and headaches in cycles. It starts with a flu-like illness with aching muscles, headache, nausea and fever. Then you may have a shaking chill for one to two hours and a rapid rise in temperature—as high as 106°F (41°С). The fever will last three to six hours and then suddenly drop. Along with the fever, you may have severe headache, nausea, coughing, rapid pulse and breathing, and a drop in blood pressure, followed by profuse sweating, weakness, and a tendency to sleep. A day or two goes by and the cycle starts again—chills, fever, sweating.

If you become ill with chills and fever after being in an area with malaria, you must see a doctor and inform him about your recent travel. Delaying treatment of falciparum malaria can have grave consequences. You should insist on a blood test for malaria even if your doctor thinks you have the “flu.” This is important because malaria is often misdiagnosed by North American doctors.

Tests

Blood tests and blood counts are necessary for a diagnosis. The parasite can be detected in blood smears placed on slides. These are called serial thick and thin blood smears and must be done over a 72-hour period. Antibody tests are not always helpful because many people have antibodies from past infections.

How Sick Will You Be?

The on-again, off-again cycle of chills, fever, and sweating may last for a week to a month. People with chronic forms of malaria who are not treated can have relapses for as long as 50 years.
Once in the blood, the parasites damage red blood cells, causing anemia. Both the liver and spleen become enlarged and tender, detectable on physical exam. In falciparum malaria red blood cells become sticky and block the small blood vessels to the brain, kidney, and lungs, damaging these organs.

Incubation Period

The incubation period is 8 to 12 days for falciparum malaria, and as many as 30 days for the other types. With some strains of P. vivax, however, the incubation period may be as long as eight to ten months.

Infectiousness

You are infectious to mosquitoes (not people) as long as you have parasites in your blood. For untreated or insufficiently treated people, this ranges from one to three years. Do not give blood if you have been diagnosed with P. malariae because you can transmit the infection to others through your blood for 40 years.

Immunity

You obtain only partial immunity after a malaria infection. You can become sick if you are infected by another strain.

Complications

Persons infected with falciparum malaria, the killer variety, can die within several days if they do not receive antibiotics. It is a medical emergency. Falciparum malaria may trigger lung failure, kidney failure, and brain damage leading to coma and death. Irreversible complications can come on suddenly. The disease is more severe in children. More than ten percent of untreated children infected with malaria die. During pregnancy it has caused prematurity, abortion, and stillbirth.

How Do You Cure It?

If caught in the early stages, malaria is usually cured. Which drugs are used, by what route, and for how long depend on where you contracted malaria and how sick you are. Your doctor can consult with a tropical disease specialist for the most up-to-date malarial treatments by calling the CDC Malaria branch at (404) 488-7760 or the Tropical Health and Quarantine Division at the Canadian Laboratory for Disease Control at (613) 957-8739.

For all strains except falciparum, the most serious strain, the treatment is usually chloroquine (Aralen) orally for three days. For serious conditions, quinine or quini-dine may be given intravenously.
If you catch falciparum malaria in the Dominican Republic, Haiti, Central America west of the Panama Canal, the Middle East, or Egypt, you can still be cured with chloroquine. However, almost all strains of falciparum malaria in Africa, South Africa, India, and Southeast Asia are now resistant to chloroquine. In Thailand and Cambodia there are strains of falciparum malaria that have some resistance to most known drugs.

Chloroquine-resistant strains are treated orally with quinine sulphate and tetracycline. This combination effects a cure about 90 percent of the time. Generally, you will receive at least one antibiotic for seven days. If you are very sick, you will need intensive care treatment and IV antibiotics for the first three days.

Falciparum malaria requires hospitalization. Treatment includes antimalarial drugs in varying combinations and doses depending on the degree of drug-resistance of the strain. You may need IV fluids, red blood cell transfusions, dialysis if your kidneys fail, and assisted breathing if lung complications develop.

You may be given a drug called primaquine to take after you recover from either P. vivax or P. ovale to prevent relapses. People who have G6PD deficiency—usually males of African or Mediterranean backgrounds—cannot take this drug.

New Drugs

A Chinese herb called Qinghaosu—the western name is artemisinin—is used effectively in China and Southeast Asia to combat severe malaria. It became available in France and many other countries, (but not the U.S.) in 1994- Another effective new drug, halofantrine, should be available in the United States in 1995. It is available abroad.

How Do You Prevent It?

The World Health Association (WHO) has been trying to eradicate malaria for the past 30 years by controlling mosquitoes. At first, their efforts were successful. DDT wiped the mosquitoes out, and antimalarial drugs prevented or cured people who were exposed or infected. Malaria rates dropped all over the world.

Because both the mosquito and the parasite are now highly resistant to eradication, prevention aims at avoiding mosquito bites and taking preventive medicine. Travelers and personnel stationed in Africa who observe the following preventive measures get fewer malaria infections than those who do not.

Preventing Mosquito Bites

The best way to prevent malaria is to avoid being bitten by infected mosquitoes. Follow these precautions if you are traveling to malaria countries and planning to spend time in rural areas. You can buy all these supplies in hardware, backpacking, or military surplus stores. Insect repellants containing DEET are available in pharmacies.

■ Try to stay indoors in well-screened areas between dusk and dawn when mosquitoes are feeding.
■ Sleep inside mosquito nets soaked in repellent.
■ Wear clothes that cover most of your body.
■ Use insect repellent containing DEET for exposed skin—but use DEET sparingly because it can be toxic at high concentrations. Do not use a concentration higher than 35 percent on children. This concentration keeps the mosquitoes away for four to six hours only. Longer protection is available from a newly available preparation of 35 percent DEET. Adults can use 95 percent DEET, which protects for 10 to 12 hours.
■ Do not inhale DEET or get it into your eyes.
■ Don’t put DEET on children’s hands.
■ Don’t use DEET on broken or irritated skin.
■ Wash DEET off after coming indoors, if you don’t plan to go outdoors in the evening.
■ Use a spray containing pyrethrium to spray in living and sleeping areas during evenings and nights.
■ Spray permethrin (Permanone) on your clothes and bednets. It works for several weeks after one application.

Although the Anopheles mosquito is only active at night, mosquitoes that spread such serious diseases as dengue fever (see page 63) do feed during the day. To avoid these diseases, don’t go unprotected at any time.

Pre-Exposure Prevention

Before your trip, call the CDC Travelers Hotline at (404) 332-4559, or the Malaria Hotline at (404) 332-4555, to find out what the current recommendations for preventive medicines are. Or call the fax information service at (404) 332-4565 and ask for fax documents #221010, #221011, and #221012. For information about malaria treatment and to report cases acquired in the United States call (404) 488-7760. The 1994 recommendations for chloroquine-resistant areas are;

1. Mefloquine (Lariam). Take mefloquine once a week—one week before leaving, every week while in the malarial area, and for four weeks after leaving the area. The side effects—stomach upsets and dizziness—are mild and temporary. Mefloquine is not recommended for:

■ Pregnant women during the first 14 weeks. Your doctor can call CDC to discuss the safety of mefloquine later in pregnancy.
■ Children lighter than 30 pounds (15 kg).
■ Travelers who have a history of epilepsy or psychiatric disorders or with heart arrhythmias.
■ Travelers with a known sensitivity to mefloquine.

2. Doxycycline. Recommended along the borders of Thailand and for those who cannot take mefloquine. Take doxycycline once a day—the day before you leave, every day while you’re in the malarial area, and every day for four weeks after you leave. One side effect from doxycycline is skin photosensitivity; to counter this, wear a hat, use UVA sun block, and take the drug in the evening with food. A side effect in women is vaginal yeast infections. Discuss this with your doctor before leaving. Doxycycline is not recommended for:

■ Pregnant women
■ Children younger than nine years old
■ Travelers who have a hypersensitivity to doxycycline

3. Chloroquine (Aralen). Chloroquine is for travelers who cannot take either mefloquine or doxycycline. It is taken once a week in the same manner as mefloquine. Chloroquine works better against resistant strains when taken with proguanil (Paludrine). Proguanil is not available in the United States, but you can get it in Canada or abroad. Adults take 200 mg of proguanil every day.

If you take chloroquine for prevention in an area with chloroquine-resistant malaria (see page 230), there is a good chance that it may not work. Take a medicine called pyrimethamine-sulfadoxine (Fansidar) with you. You cannot take this medicine if you have any history of sulfa allergy. This medicine is for self-treatment of malaria only if no medical care is available within 24 hours. Take three tablets as soon as you develop any fever. This is a temporary measure only, and you must seek medical care as soon as possible. Continue taking your weekly dose of chloroquine.

The side effects of chloroquine include upset stomach, headache, dizziness, blurred vision, and itching. These are usually mild.

In the United States you can buy chloroquine in tablet form only. It tastes bitter and is difficult to give to small children. Ask the pharmacist to pulverize the tablets and prepare gelatin capsules with calculated pediatric doses. You can mix the powder with a small amount of food to hide the taste.

You can buy chloroquine in liquid form overseas. Calculate the dose very carefully according to the concentration of the liquid and your child’s weight.

You can take chloroquine alone for malaria prevention if you are going to an area where malaria is not resistant.

Pregnant women and children must take preventive drugs against malaria. Until recently, the only drugs safe for pregnant women were chloroquine and proguanil. Now experts consider mefloquine safe in the last six months of pregnancy. Young children and pregnant women who cannot take mefloquine should if at all possible avoid traveling to areas with chloroquine-resistant P. falciparum malaria.
Young children can die from taking an overdose of antimalarial drugs. Store the medicines in childproof containers, preferably in locked cabinets or boxes out of children’s reach.

Vaccines

Several researchers are working on malaria vaccines. Because the parasite has such a complex life cycle within humans, it is a difficult challenge. But a Colombian physician has developed a promising vaccine that protected 40 to 60 percent of those exposed in field trials in both South America and Africa. This doesn’t sound like a very high percentage but it is the best so far. As of this writing it was not licensed for use.

We desperately need more research into new drugs. Otherwise, we will inhabit a world afflicted by uncontrollable malaria.

Borrelia burgdorferi, a corkscrew shaped bacteria known as a spirochete, causes Lyme disease. It got its name from Dr. Willy Burgdorfer, who discovered it in 1982.

Although the symptoms of the disease had been reported by people as early as 1908 in Sweden and 1970 in Wisconsin, it was not then recognized as a specific disease. In 1975, in Old Lyme, Connecticut, 50 people including many children came down with a strange disease that resulted in severe arthritis. Scientists studied these people, and in 1982 discovered the cause of the disease and how it was spread—by ticks. They named it Lyme disease after the town in Connecticut. Of course, the residents of this town are not pleased with the notoriety this name has brought them.

Lyme disease is the most common disease in the United States that can be caught from animals or insects. Deer ticks infected with the Lyme bacteria are the culprits. It is not spread from person to person. If you like the great outdoors, you are a potential victim of this tiny creature.

The deer tick has a complex two-year life cycle: Adult ticks feed and mate on large animals, especially deer, in the fall and early winter. In early spring the female ticks drop off the large animal to lay eggs on the ground. The female then dies. After several weeks eggs hatch into larvae. In the spring and summer, larvae feed on white footed mice. The larvae then hibernate until the next spring when they molt into nymphs (baby ticks). All the next summer these nymphs feed on mice. The nymphs molt into adults in the fall, feed on deer all winter, and the two year cycle goes on.

Because white-tailed deer are large and abundant, they are the most common hosts for adult ticks. Ticks may also feed on foxes, raccoons, cows, horses, dogs, and cats. The adult ticks are found in brushy wooded areas about three feet off the ground. The ticks attach to the animal or human host when it brushes up against them.

Larvae and nymphs who feed on infected mice become infected with Lyme disease bacteria, which multiply in the tissues of the mouse. These ticks have very aggressive feeding behavior and spread the disease when they bite mice, other animals, and humans.

Forty-seven states have reported cases of Lyme disease. Connecticut, the state where it first was identified, had the highest rate of infection in 1992: 54 cases for every 100,000 people. New York state had the highest total number of cases. Other states reporting large numbers of cases are Massachusetts, Rhode Island, Pennsylvania, New Jersey, Delaware, Maryland, Virginia, Georgia, North Carolina, Missouri, Minnesota, Ohio, and California. The Canadian provinces of Quebec, Ontario, Manitoba, and British Columbia have reported several cases, but in Canada the total number of annually reported cases is barely 100. It is also seen in several countries of Northern Europe.

Because the deer population is growing rapidly, so are the number of reported Lyme disease victims. In 1994, Lyme disease struck 8,300 people of all ages. Cases have been reported in people from ages 2 to 88.

How Do You Get It?

You get Lyme disease from being bitten by an infected deer tick. But not everyone who is bitten gets sick. Some studies show that only ten percent of those bitten come down with Lyme disease. This may be because the tick must sink its mouth parts into a person’s body and stay attached, sucking blood, for more than 24 hours to allow enough bacteria to enter the bloodstream and cause infection. So, if you remove the I tick before 24 hours, you won’t be infected.

Humans are usually bitten by the nymphs in June and July, when the nymphs are attaching to the mice and people are outdoors with bare skin. Cases can occur, however, anytime between March and October.

Although the most likely places for catching Lyme disease are wooded areas, nature reserves, and suburban gardens near areas inhabited by large numbers of deer, there are a few reports of Lyme disease in people who have never left the city. In Bah timore, Maryland, in 1989, a 44-year-old man who worked for the Baltimore Zoo I came down with Lyme disease. His case was investigated and the culprits were determined to be infected ticks found on raccoons and mice. Because only two or three deer live in this inner city park, it was concluded that adult ticks could survive the winter by feeding on mammals other than deer, such as those found in zoos. This was an unusual occurrence, and no other zoo workers became sick. Visitors to the zoo were not considered to be at risk. The zoo worker was treated and recovered completely.

How Do You Know If You Have It?

It may be hard to tell if you have Lyme disease because it mimics other illnesses, and in the early stages, there is no accurate test to detect it. But if you are alert and familiar with the symptoms, you should be able to recognize it. Lyme disease occurs in stages. The time interval between stages varies widely. Several weeks to several months can elapse between stages. Symptoms come and go, but if new symptoms appear, it usually signals the beginning of the next stage.

First Stage Symptoms. The first, most significant symptom, which occurs in 70 to 80 percent of Lyme disease victims, is a red rash called erythema chronicum migrans that develops at the site of the tick bite 3 to 32 days after the bite. This rash resembles a red circular patch, which expands over a few weeks to as large as 18 inches (46 cm) in diameter in varying shapes. After the first rash appears, a similar rash may develop in other places such as the thigh, groin, trunk, armpits, or face. Usually the center of the patch clears as it expands, causing a ringlike appearance that some people call a “bull’s eye” rash. Patches may feel warm but are not painful. Any rash that is at least 2 inches (5 cm) in diameter should be considered evidence of Lyme disease.

Flu-like symptoms may develop within a few days to a month after the tick bite, including headaches, chills and fever, aching muscles, stiff neck, joint pains, tiredness, and swollen glands. These symptoms usually come and go. Diagnosis of Lyme disease in the first stage is based on these flu-like symptoms, the presence of the rash, and history of exposure to ticks. People who are unaware of their exposure to ticks or to what Lyme disease is are often diagnosed and treated for a “virus” at this stage.

Second Stage Symptoms. Weeks or months later, untreated Lyme disease will reach its second stage. Symptoms may include migraine-like headaches and arthritis with pain and swelling in hips, knees, shoulders, and other joints. A small percentage (15 to 20 percent) of Lyme disease victims will suffer from nervous system involvement. Such problems as numbness, pain and weakness in arms and legs, muscle weakness of the face (Bell’s palsy), stiff neck, meningitis, memory loss, impaired vision and hearing, or severe fatigue can occur. Only about one in ten untreated victims have problems affecting their heart in the second stage. Their symptoms include dizziness, weakness, and an irregular heartbeat.

Late Stage Symptoms. If untreated, Lyme disease can progress to the late stage, which may start months or even years after the initial infection from the tick bite, but averages six months. Severe arthritis may occur, causing swelling and pain in large joints, especially knees, shoulders, or elbows, but usually not the same joint on both sides of the body at once. Heart and nervous system problems can also occur in late stage Lyme disease.

Tests

Blood tests to diagnose Lyme disease are helpful, but not always accurate. Better tests will soon be available. The best test now in use is called the ELISA test, which is preferred over the fluorescent antibody test (IFA). These tests look for antibodies to the bacteria in your blood. In the first two weeks the test is able to find antibodies in only half the people who have Lyme disease. These results are called false negatives because the test is negative even though Lyme disease is actually present. The test may also be positive in people who do not have Lyme disease. This is called a false positive.
In the later stages of the disease, when there are more antibodies, the tests are more accurate but still not perfect. The test can be useful in the later stages because the rash will be gone and you probably won’t be able to remember an exposure to ticks that happened many months ago.
Even though treatment may not be as successful in the later stages, you need to be tested. If you know what disease you are suffering from, you won’t receive the wrong treatment.

How Sick Will You Be?

Severity of symptoms in Lyme disease varies widely from person to person and from week to week.
Most adults and children experience fever, tiredness, headache, and joint paints intermittently. If untreated, the symptoms change over a period of several weeks. First stage symptoms are usually mild. Later stages can be severe and persistent. Audrey, the florist in Philadelphia, gets tingling in her mouth, arms, and legs and sometimes feels a sensation of lights exploding inside her head.
Some people have loss of memory and can’t concentrate. Patients have told me about migraine headaches, dizziness, fatigue, weakness, and irregular heartbeat. Lyme disease affects different people differently.

If you don’t realize that you have Lyme disease and are not treated, the rash and other symptoms will slowly go away. Some people (the percentage is unknown) who go untreated do not progress to the second stage. But for others, the disease will not go away.

Incubation Period

The incubation period is from 3 to 32 days.

Infectiousness

You can’t catch Lyme disease from another person, only from an infected tick.

Immunity

You can get it more than once. People who work outdoors in areas such as nature reserves or gardens have been infected, successfully treated, and reinfected.

Complications

If it’s not diagnosed and treated early, Lyme disease can lead to serious arthritis or heart or nervous system problems. In a few cases permanent damage to the joints results from untreated late stage disease. In some people the arthritis becomes chronic—it comes and goes but is never cured.

PREGNANCY Most babies born to women who were infected during pregnancy are normal. However, the spirochete can cross the placenta and cause damage to the fetus. Early studies show that women infected with Lyme disease during pregnancy have a slightly higher risk of miscarriage, stillbirth, or having babies born with heart problems or other disabilities. The risk appears to be small, but how small is not yet known.

How Do You Cure It?

Lyme disease is cured with antibiotics. If Lyme disease is diagnosed in its early stage when the rash is present, treatment is successful and recovery is rapid. It’s harder to treat the disease at the second and late stages. In the first stage the usual treatment for children older than nine and adults is tetracycline four times a day or doxycycline twice a day by mouth for 10 to 14 days. Children younger than nine years and pregnant women take either penicillin or amoxicillin three times a day by mouth.
If symptoms persist after 10 to 14 days of treatment, the antibiotics are continued until all the symptoms are gone. It is very rare that treatment will take longer than 30 days.

For most people in whom Lyme disease is not detected until the second stage, the same antibiotics by mouth will be tried for 10 to 14 days. This should do the trick. Sometimes, however, antibiotics don’t work as well at this stage because the bacteria may already have infected joint, heart, and nerve tissue. For these few who have no improvement in symptoms, or even get worse, intravenous therapy will be the next step. Normally this requires hospitalization for the first few days to make sure there is no reaction to the antibiotics. Before discharge, the nurses will teach you how to give IV medication at home. You will also be given help from a home health registered nurse.

Ceftriaxone (Rocephin) is the recommended antibiotic for IV use. It’s given for 14 days initially and another two weeks if symptoms persist. This therapy may have to be repeated every time there is a serious recurrence. But recurrences are uncommon; most people recover when first treated with antibiotics.

Nursing Care

You can give acetaminophen (Tylenol) or aspirin for adults every four hours or as needed for headaches and fever, as well as joint pains. Use warm water packs to help ease joint pains. Give backrubs and light massages to soothe aching muscles. Give plenty of rest, provide nutritious appealing meals, and give lots of support and attention. Become well informed on your patient’s prescribed treatments, and be sure she takes the prescribed medication correctly. If the antibiotics cause reactions or stomach upsets, call the doctor, who can try a different one. Don’t just stop giving them.
Don’t make your patient feel guilty for not taking proper precautions. It’s too late now, and people who get sick feel bad enough without family or friends making it worse. Anyone with a disease needs and deserves compassion. Emotional support and comfort are very important because they can help the body’s immune system fight infection.

If you are caring for someone suffering from the later stages of Lyme disease, try to be sensitive to the on-again, off-again nature of the disease. Some days your patient will feel wonderful and convinced he’s cured. The next day he may suffer a relapse and feel awful. This can be very discouraging, especially if the family doesn’t understand or sympathize with the good and bad days. Remember that this is par for the course with Lyme disease. Try to keep his spirits up. If he is receiving antibiotics, remind him that he can soon expect to feel much better.

How Do You Prevent It?

Education is the best prevention because there is no vaccine available yet and no effective way to eliminate ticks. A vaccine against Lyme disease is currently being tested in humans with promising results. It may be available in 1996. One study published in August 1992 found that people who live in areas with a high number of infected ticks can prevent infection by taking antibiotics right after a tick bite.

The surest prevention—avoiding fields, woods, and gardens where deer ticks are found—is not practical or desirable for most of us and especially not for our children. Some people advocate getting rid of deer to eliminate Lyme disease, as was done on Great Island off Cape Cod, where they eliminated the entire deer herd. No cases of Lyme disease occurred after the deer were gone. But besides not being practical, this approach may not work in the long run because, as was shown at the Baltimore Zoo, the ticks can live on large mammals other than deer if they have to.

Pregnant women living in an area with a very high rate of Lyme disease should consider staying out of the woods and camping areas completely during the summer months. If you do notice a tick bite, or have any Lyme disease symptoms, be sure to contact your doctor immediately.

Preventive Measures

Do not let the fear of Lyme disease keep you from enjoying outdoor activities. Be careful, use common sense, and you can still enjoy a lovely walk in the woods while protecting yourself and your family from Lyme disease.

1. Wear protective clothing. Wear long-sleeve shirts and long pants tucked into socks, and a hat. Wear light-colored clothing so you can see the ticks on your clothes.

2. Use a repellent containing DEET. Spraying an insect repellent containing 20 to 30 percent DEET on your clothes or skin will prevent tick attachment about 90 percent of the time. Be cautious when spraying DEET on children. There are a few reports of seizures in children after they were sprayed with DEET.

Follow these rules when applying DEET:

■ Do not use concentrations greater than 35 percent for children, and apply sparingly. One application lasts four to eight hours, and some newer products may last longer.
■ Do not inhale or get DEET into your eyes.
■ Never spray DEET on a child’s hands because this can spread DEET to your child’s eyes or mouth.
■ Never spray DEET on wounds or broken or irritated skin.
■ Wash repellent-sprayed skin as soon as you come indoors.
■ If you suspect a reaction to insect repellent, wash the sprayed area with soap and water, and call your doctor or emergency room. Save the repellent can and take it with you. A repellent containing permethrin can also be sprayed on your clothing to prevent tick attachment. It is not safe to use on exposed skin or children’s clothes, but adult outdoor workers may find it useful.

3. Inspect for tick bites. If you are out all day, check for tick bites every three to four hours. As soon as you come in from outdoors remove, wash and dry your clothing at a high temperature. Shower and inspect everybody for ticks, including your dogs and cats.

4. Remove ticks. This is important. If you remove the tick before 24 hours have elapsed, you should be okay. Remember, the tick needs to take a 24-hour blood meal for enough bacteria to get into your bloodstream to cause Lyme disease infection. Learn to recognize what a deer tick looks like. It is very small—much smaller than a dog tick. The nymph, which usually bites humans, is about the size of a pencil point. Remove the tick by placing small tweezers or forceps close to the head of the tick and pulling straight back with a steady force. Be careful. Make sure the whole tick is removed. Wash and apply antiseptic (alcohol, hydrogen peroxide, or iodine) to the bite area after the tick is removed. Don’t squeeze or crush the tick to kill it, even if your kids really want to do this. If it is infected, squeezing will release bacteria onto your hands. Put the tick in a jar filled with alcohol, then cover and save it. If you develop symptoms later on, this insect specimen will be helpful in diagnosing Lyme disease.

5. Keep pets free of ticks. Your dog or cat can get Lyme disease and will have the same symptoms as humans, except fot the rash. Your children cannot catch it from their pets, but they can catch it from the infected ticks living on the dogs. To prevent this, put tick repellent collars on all pets, and inspect them daily for tick bites and remove ticks if possible. It can be close to impossible to find tiny ticks on a furry dog. Dogs who are outside all day in areas with large numbers of ticks may come home with more than 50 tick bites. Don’t try to remove all these. It’s too risky to you. Have your veterinarian remove the ticks.

6. Treat the environment. Scientists are now focusing on treating the environment to get rid of the ticks. Three pesticides that are approved by the Environmental Protection Agency effectively reduced the tick population and the risk of Lyme disease by 95 percent in several studies: carbaryl (Sevin), chlor-pyrifos (Dursban), and cyflutherin (Tempo). You can apply one of these to your yard at the start of Lyme season.

7. Wear gloves when hunting or handling animals. Hunters and animal handlers who have open cuts or wounds on their hands should wear gloves when handling a bleeding animal that may be infected because it is possible for Lyme disease to spread from an infected animal’s blood to the open cut. There have been no reports of this actually having happened, however.

The rod-shaped bacterium, called Listeria monocytogenes, is found in cow’s milk, animal and human feces, soil, and leafy vegetables.

How Do You Get It?

The disease is usually linked to unpasteurized milk or cheese, so eating any soft cheese—feta, brie, camembert, blue-veined, or Mexican-style—puts you at a slight risk. Cases have also been linked to foods bought at store deli counters and to non-reheated hot dogs. People with poor immune systems have caught it from eating undercooked chicken.

Listeriosis is an uncommon infection. We often eat soft cheese or hot dogs from street stands or at picnics, yet very few of us come down with listeria. Many people probably carry the bacteria as part of their normal flora.

Babies are infected through the placenta before birth or during delivery through the birth canal.
Listeriosis can be spread through sexual contact, although it is not known how often this happens. Except for pregnancy, this is a disease generally caught through food, not from other people.
Listeriosis is often reported in large outbreaks, but isolated cases occur as well. The rate is about 7.5 cases for every 1 million people. You can get it any time of year.

Besides pregnant women, other reported cases occur in adults over 40 and adults with deficient immune systems, such as those with cancer or AIDS, or transplant recipients who take drugs that suppress their immune systems. Immunocompromised individuals can develop listeria meningitis following exposure. Healthy, young, nonpregnant adults are at little risk.

Listeriosis used to be considered a veterinary problem because it causes abortions and infections in cattle. It became recognized as a human problem in 1981 when a Canadian outbreak was traced to tainted cole slaw that came from cabbage grown in soil fertilized with manure from Listeria-infected sheep.

In 1985, an outbreak traced to Mexican-style soft cheese took place in California. More than 150 people were sick, including many pregnant women. Of the 48 deaths, 30 were fetuses or newborns. In 1990, listeriosis affected 1,850 people in the United States, of whom more than 400 died. In 1992, an outbreak affecting 279 people in France was traced to frozen pork tongue. It caused 63 deaths, including seven newborns. Twenty-two pregnant women suffered miscarriages. Canadian officials reported 39 cases that same year.

How Do You Know If You Have It?

Healthy adults may have a flu-like illness or no symptoms at all. But if a pregnant woman becomes infected, it can be devastating to the fetus or cause stillbirth. Pregnant women with listeria have a fever, tiredness, headache, sore throat, dry cough, or back pain. These symptoms last a few days and then, as the mother is feeling better, she notices that her fetus is moving less than before she got sick. The result may be a miscarriage as late as the sixth month of pregnancy or a stillborn or very ill infant born prematurely.

Tests

A pregnant woman with a fever and flu-like illness must be tested for listeriosis if there is any suspicion that she may have been exposed. Because Listeria resembles other common bacteria that do not cause disease and which the lab would not report to the doctor, the lab must be alerted to watch for Listeria when analyzing blood cultures. Blood tests that look for Listeria antibodies are also available but difficult to interpret.

How Sick Will You Be?

Healthy nonpregnant adults have a mild illness that probably won’t even be diagnosed unless an ongoing major outbreak is being investigated.

Listeriosis can hit a baby early (within the first four days of life) or late (after one to six weeks). In the early form, the baby usually becomes infected while still in the womb. Such a baby will probably be premature, have a low birth weight, and be very ill at birth, with breathing problems, bluish skin, and a cold body temperature. Sometimes a skin rash and thick, sticky conjunctivitis occur. If the baby survives, she will be very ill and may have a bloodstream infection or meningitis. About half such babies die, even if treated in the first four days of life.

In late onset listeriosis, babies are born at full term with a normal birth weight. The baby is infected during delivery. Meningitis is the usual form the infection takes. These babies are also very sick and as many as 40 percent die. Some surviving babies have permanent brain damage or mental retardation.

Incubation Period

The incubation period is long and variable. People have come down with listeriosis from three to 70 days after eating the contaminated food.

Immunity

There’s no such thing as building up resistance to it.

Infectiousness

Women who deliver infected babies have infectious vaginal discharge or urine for seven to ten days.

Complications

In immunocompromised adults who develop listeria meningitis, symptoms start with fever, intense headache, nausea, and vomiting. Delirium and coma, collapse, and shock may follow. Sometimes abscesses and skin rashes appear.

How Do You Cure It?

Antibiotics are most useful when given to pregnant women to prevent disease in the fetus. Recommended antibiotics are ampicillin and gentamicin. Treatment is usually by the intravenous route for 14 to 21 days. Sick newborns and adults with listeria meningitis will also be treated with antibiotics. The cure rate, however, is not high.

If you are pregnant or suffer from an immune disorder and you have symptoms resembling listeriosis, contact your doctor. Try to recall what you ate that might have caused the disease. Possibilities include raw or undercooked meat, pork, or chicken; unwashed raw vegetables; unpasteurized milk or cheese; soft cheese; or hot dogs that were not thoroughly heated.

In July 1987, eight teenage boys living on the island of Kauai in the state of Hawaii swam every day in the Waimea River. These boys all came down with a flu-like illness in the same week. Five were put in the hospital. Their blood was sent to the CDC for testing, and they were diagnosed with leptospirosis. They caught it from swimming in river water that contained infected animals’ urine.

Leptospirosis is a rare bacterial disease that is caught from contact with animal’s urine that is infected by leptospires, which are spiral-shaped bacteria called spiro-chetes. Other spirochetes cause syphilis and Lyme disease. Scientists have identified more than 200 different types of leptospires some cause mild illness, others serious illness.

How Do You Get It?

People get leptospirosis when broken skin or mucous membranes (eyes, nose, mouth) contact either infected animal urine or water, soil, or vegetation contaminated with such urine.

The bacteria survive best in warm water 72°F (22°C) that is fairly stagnant. Most reported cases have occurred from swimming, wading, or splashing in pools, streams, or puddles contaminated with infected dog or rat urine.

The animals most commonly infected are rats, dogs, swine, and raccoons. Sixty-four percent of the cattle that grazed near the Waimea River in Hawaii were infected, but pigs, goats, mongooses, and other rodents also roam the valley. As a result, the investigators could not determine which animals contaminated the river.

Leptospirosis occurs worldwide and is more common in the tropics. Most cases occur in the summer. Hawaii has the highest number of American cases.

People who work with animals, on farms, in rice paddies or sugar cane fields, or in sewers are most at risk. Seventy-five percent of victims are male, from teenagers to young adults.

How Do You Know If You Have It?

Leptospirosis has two phases: The first phase starts suddenly with headaches, severe muscle pains in the calves and thighs, chills, and fever, and lasts 4 to 12 days. The second phase starts a few days after your temperature has returned to normal. Fever will return, and you may get meningitis because the bacteria will have spread to the lining of the spinal cord, causing headaches and a stiff neck. Other serious symptoms include jaundice, mental confusion, depression, or decreased urine output. The second phase lasts another seven to ten days.

Leptospirosis is often mistaken for viral meningitis or hepatitis. However, the two distinct phases differentiate it from these infections. Also, you must have been in contact with an animal or with water in which animals urinate to get leptospirosis.

Tests

Samples of blood, urine, or fluid from around the spinal cord will grow bacteria on special culture plates. The doctor must request such testing; it is not routinely done. The blood can also be sent to state laboratories for antibody testing.

How Sick Will You Be?

Some people with leptospirosis have no symptoms at all, others have a mild illness, and still others have a severe illness with meningitis and liver failure. It depends upon what type of leptospire infects you.

Incubation Period

The incubation period is 2 to 26 days, with an average of 7 to 13 days.

Infectiousness

The leptospires are excreted in your urine for as long as one month. However, it is rare for this infection to spread from person to person.

Immunity

You become immune after infection, but can become ill again if you are exposed to a different type of leptospire.

Complications

Weil’s syndrome is a severe form of leptospirosis that affects the liver and kidneys, causing jaundice, decreased urine, change in consciousness, fevers, internal bleeding, and anemia. Almost everyone recovers completely.

How Do You Cure It?

Penicillin given intravenously does the job best. For milder illnesses, you can take ampicillin or doxycycline by mouth for five to seven days. Studies show that even if you start the antibiotic seven days into your illness, it will still work.

Nursing Care

Rest, and treat the fever with acetaminophen. Contact your doctor about these signs:

■ Headaches
■ Stiff neck
■ Changes in amount or color of urine
■ Jaundice
■ Nausea
■ Bruising
■ Rashes
■ Change in consciousness

How Do You Prevent It?

Avoid swimming or wading in warm waters that may be contaminated by animal urine.

Animals can be vaccinated against leptospirosis, but the vaccine only prevents illness, not infection. The animal can still shed bacteria in its urine and infect humans. Animal workers who may become infected around animals must wear protective clothing. A Panama study proved that doxycycline taken once weekly prevents leptospirosis during periods of high exposure. People in Japan, China, Italy, Spain, France, and Israel who work in high risk areas are vaccinated.

If your doctor diagnoses leptospirosis, it must be reported to the health department. It is not a notifiable disease in Canada. Fifty-one cases of leptospirosis were reported to the CDC in 1993. Although there are more unreported and undiagnosed cases, this is still a rare disease.

Many of us remember the horrors of leprosy depicted in the movie Ben Hur, in which lepers with filthy bandages wrapped around decaying limbs were cast out of society. Other horrible and conspicuous skin diseases were called leprosy in biblical times, but archaeologists believe from studying skeletons that the disease we call leprosy did not appear until the sixth century, when it first appeared in Egypt, France, and Britain.

In 1874, a Norwegian named Armauer Hansen identified the bacterium that causes leprosy. As a result, the medical term for leprosy is “Hansen’s disease.” Because of the stigma attached to the name “leprosy,” public health authorities and health professionals prefer to call it Hansen’s disease.

A rod-shaped bacterium called Mycobacterium leprae causes leprosy. There are two different kinds—lepromatous and tuberculoid—and a borderline type that is a mixture of the two. Lepromatous is the most contagious type.

How Do You Get It?

Leprosy can be caught by prolonged or intimate household contact with someone who has the lepromatous or borderline type in which the skin lesions and the nasal secretions are filled with leprosy bacteria. The bacteria can live for seven days in dried nasal secretions.

Malnutrition, crowded living quarters, lack of soap and running water, and bedbugs may contribute to the disease’s spread. Very young children do not usually get leprosy unless they are infected in the womb because the disease has a long incubation period.

From the sixth to the fourteenth century leprosy affected thousands throughout Europe who were housed in Leprosaria, quarantined areas set outside medieval towns. The Black Death that swept through the continent in 1346 killed off many of those with leprosy, after which time leprosy became much less common, except in Scandinavia. Several theories try to explain the disappearance of the disease: changes in diet; the emergence of ТВ, which gives some immunity to leprosy; the use of wool clothing for warmth, which decreased skin-to-skin contact; or the most likely explanation, reduced population, which resulted in more spacious living quarters.

Large groups of refugees entered the United States in the late 1970s and early 1980s from Vietnam, Laos, and Cambodia, some bringing leprosy with them. Immigration officials screened these people for leprosy, but did not detect signs of illness at the time they entered the country. The result was an increase in imported leprosy that peaked in 1985 and ended in 1988. In 1985, doctors reported 361 new leprosy cases, but by 1991, the number of cases was down to 154. Most of the infections appeared in the first year after the refugees arrived. None of these people gave leprosy to their household members or other Americans after they arrived. Better housing conditions and nutrition in the United States are credited for this lack of transmission.

Small pockets of leprosy remain in Hawaii, Louisiana, Texas, California, and Puerto Rico. There are about 3,000 cases currently under treatment in the United States. Worldwide, leprosy is endemic in Asia, including the Philippines, Indonesia, India, Bangladesh, and Myanmar (Burma) as well as in tropical Africa, some Pacific Islands, and some areas of Latin America, affecting around five to six million people in 93 countries.

It was once thought that this bacteria infected only humans, but recently about 15 percent of the wild armadillos in parts of Louisiana and Texas have been found to be infected with leprosy.

How Do You Know If You Have It?

Lepromatous. Lepromatous leprosy causes lumps, and multiple patches on your skin on both sides of the body, especially on the face. Sometimes it makes the eyebrows fall out. There may be growths inside the nose and inflammation in the eyes. This is the most contagious type because bacteria is present in the skin lesions and in the nose.

Tuberculoid. Tuberculoid leprosy causes very few skin lesions, which are lighter than the victim’s skin color or red, often with a clearing in the center. The lesions are not symmetrical on the body. Eventually there may be severe peripheral nerve involvement—tingling, lack of feeling, muscle wasting, and ulceration in fingers and toes. Hand muscles get weak, causing the fingers to curl inward.
Borderline. Skin lesions in borderline leprosy are a mixture of the other two types.

Tests

An experienced pathologist can differentiate and diagnose leprosy from many other similar skin conditions by examining tissue from the skin lesions. Sometimes the bacteria can be identified by a skin smear examined under a microscope. There is no culture for leprosy bacteria. In many developing countries experienced doctors diagnose leprosy clinically by examining skin and nerves.

How Sick Will You Be?

Many people in areas where leprosy is present have antibodies in their blood, indicating past infection, but no symptoms. Very few exposed people get clinical illness.

Incubation Period

The incubation period is at least a few months and averages about five years.

Infectiousness

Antibiotics decrease infectivity quickly. After seven days of antibiotics that include rifampin, you are no longer infectious. People who do not or cannot take rifampin, which is prohibitively expensive in many developing countries, may be infectious for about three months with other antibiotic treatments. Without treatment people with lepromatous leprosy may remain infectious for years. Recent studies show that half of those with tuberculoid leprosy will heal spontaneously without treatment.

Complications

If untreated, leprosy over years may destroy nerve endings causing loss of feeling or weakness in arms and legs. Lack of feelings in fingers and toes leads to trauma, cuts, ulceration, bone damage, and, without appropriate treatment, the eventual loss of fingers and toes. Eye involvement may eventually cause blindness. Advanced leprosy may reach the liver and kidneys, leading to renal failure and death, though this is rare and takes many years of untreated leprosy.

How Do You Cure It?

The cure requires two or more antibiotics. To cure lepromatous leprosy, the World Health Organization now recommends dapsone (DDS) daily with rifampin and clo-fazimine monthly for two years. For tuberculoid leprosy dapsone and rifampin are taken for six months.

Almost all leprosy victims are treated as outpatients. Public health workers supervise the monthly medicines.

Sometimes the antibiotics trigger serious reactions that must be controlled by steroids or other drugs. These reactions are a part of the immune system’s response to the death of leprosy bacteria caused by the antibiotics.

People with long-term untreated leprosy may need plastic or orthopedic surgery to correct deformed limbs.

Nursing Care

Always wash your hands well after caring for anyone with confirmed leprosy. Nasal secretions are the greatest risk. Carefully dispose of handkerchiefs and tissues.

How Do You Prevent It?

Vaccine

BCG, the ТВ vaccine, offers some protection against leprosy in endemic areas. Researchers are testing an improved vaccine.

Post Exposure Prevention

Household contacts. A doctor must check all household contacts thoroughly for disease. Those contacts of patients with borderline or lepromatous leprosy who are younger than 25 years old should be considered for preventive treatment for as long as three years. Doctors must report suspected leprosy to public health authorities, who will be involved with anyone receiving leprosy treatment.
For more information on treating and preventing leprosy, call the Gillis W. Long Hansen’s Disease Center (GWLHDC) in Carville, Louisiana, at (504) 642-4746 or (800) 642-2477.