Another fatal infection in your backyard:Scrub Typhus! Beware!

My family and me spent a few days during our Christmas-New Year holidays at my in-laws’ house. It was a happy time as we celebrated their wedding anniversary and the birthday of Father-in-law (Daddy). Just a day before we left, Daddy complained of slight fever. As per the physician’s advice, he took paracetamol for a few days. Since the fever was not coming down, paracetamol was given as I.V.  The blood test was repeated to verify attack of any virus and nothing adverse was noticed.

We constantly enquired over phone as we lived in a different city. Temperature became normal for two days and then again went up. He was admitted to a nearby hospital and mild fever continued for a few days more and doctors there had no clue about the disease. They said, it could be a urinary infection and started giving medicines for that. They also put him in ICU to check his cardiac status as his BP shot up. As they found the ECG and Echo normal, they told mummy that the fever will go once the urinary infection is reduced.

Meanwhile my wife took the night bus and reached the hospital in the early morning and found Daddy almost collapsed in his bed, unable to move or speak. The transition to this stage was in a matter of a few hours. Till the previous night he was moderately active and was speaking to everyone. My wife who is also a doctor asked the physician of the hospital about the status of the patient. He said, ‘he is suffering from dementia’. My wife did not believe the physician’s story of urinary infection and dementia and told him so. She said she is taking him out of the hospital to get him readmitted in a better hospital. The physician didn’t like someone questioning his theory and angrily disappeared from the scene.

Daddy was rushed in an ambulance to a nearby multi speciality hospital (SUT Hospital). By that time his kidneys and other internal organs had malfunctioned. It did not take more than a few minutes for the physician Dr Dhanya to zero in on the most probable infection: Scrub Typhus. She immediately started the appropriate antibiotic without waiting for the blood results which confirmed the disease after 24 hours. Daddy was put under life support in the ICU.

What is Scrub Typhus?

We need to be aware and beware of this as it is fast spreading all around.

Let me summarize below what WHO tells about the infection:

Scrub typhus is an acute, febrile, infectious illness that is caused by Orientia (formerly Rickettsia) sutsugamushi. It is also known as tsutsugamushi disease.

How it is transmitted?

Scrub typhus is transmitted to humans and rodents by some species of trombiculid mites (“chiggers”, Leptotrombidium deliense and others). The mite is very small (0.2 – 0.4mm) and can only be seen through a microscope or magnifying glass. Humans acquire the disease from the bite of an infected chigger. The bite of the mite leaves a characteristic black eschar that is useful to the doctor for making the diagnosis.

 In India

Scrub typhus is prevalent in many parts of India but specific data are not available. There have been outbreaks in areas located in the sub-Himalayan belt, from Jammu to Nagaland. There were reports of scrub typhus outbreaks in Himanchal Pradesh, Sikkim and Darjeeling (West Bengal) during 2003-2004 and 2007. Outbreaks of scrub typhus are reported in southern India during the cooler months of the year. Scrub typhus is a reemerging infectious disease in India. It occurs more frequently during the rainy season. However, outbreaks have been reported during the cooler season in southern India. Certain areas such as forest clearings, riverbanks, and grassy regions provide optimal conditions for the infected mites to thrive.

What are the clinical symptoms of Scrub Typhus?

The chigger bite is painless and may become noticed as a transient localized itch. Bites are often found on the groin, axillae, genetalia or neck . An eschar is often seen in humans at the site of the chigger bite. The illness begins rather suddenly with shaking chills, fever, severe headache, infection of the mucous membrane lining the eyes (the conjunctiva), and swelling of the lymph nodes. A spotted rash on the trunk may be present. Symptoms may include muscle and gastrointestinal pains. More virulent strains of O. tsutsugamushi can cause haemorrhaging and intravascular coagulation. Complications may include atypical pneumonia, overwhelming pneumonia with adult respiratory distress syndrome (ARDS)–like presentation, myocarditis, and disseminated intravascular coagulation (DIC). Patients with scrub typhus often exhibit leucopenia.

Image: Medscape.com

How to differentiate scrub typhus from other diseases?

Differentiating scrub typhus from other forms of typhus as well as from fever, typhoid and meningococcal infections is often difficult during the first several days before the Scrub Typhus initial rash appears. The most common signs are similar to a variety of other infectious diseases (typhoid fever, murine typhus, leptospirosis and dengue fever, etc.) which should be taken into consideration. The geographical location of scrub typhus, the initial sore caused by the chigger bite, and the occurrence of specific proteins capable of destroying the organism (antibodies) in the blood, provide helpful clues and are useful in establishing the diagnosis.

What diagnostic tests are available for confirmatory diagnosis of scrub typhus?

The diagnosis may be confirmed by a laboratory test such as serology. The cheapest and most easily available serological test is the Weil-Felix test, but this is notoriously unreliable. Fifty per cent of patients have a positive test result during the second week. This test is now being replaced by a complement-fixation test. It is a serological test to detect specific antibody or specific antigen in a patient’s serum

What is the effective treatment against scrub typhus?

Scrub typhus is treated with antibiotics. The drug most commonly used is doxycycline; but chloramphenicol is an alternative.

How to prevent it?

It has been shown that a single oral dose of chloramphenicol or tetracycline given every five days for a total of 35 days, with 5-day non-treatment intervals, actually produces active immunity to scrub typhus. There are no effective vaccines for scrub typhus.

In endemic areas, precautions include wearing protective clothing. Insect repellents containing dibutyl phthalate, benzyl benzoate, diethyl toluamide, and other substances can be applied to the skin and clothing to prevent chigger bites. Do not sit or lie on bare ground or grass; use a suitable ground sheet or other ground cover. Clearing of vegetation and chemical treatment of the soil may help to break up the cycle of transmission from chiggers to humans to other chiggers.

Measures to prevent the infection

The early diagnosis of acute scrub typhus can greatly reduce the chance of life threatening complications and guide optimal therapy. Awareness and education activities should be targeted at schoolchildren, teachers and women groups in endemic areas. Involvement of community-based organizations in prevention and control of scrub typhus is important.

Rodent control is a multidimensional activity that requires multisectoral cooperation. Different control strategies such as trapping, poisoning and use of natural predators are in practice. Allowing weeds to grow around buildings also encourages rats and mice. Good sanitation in and around buildings creates an environment that is less suited for rodent populations. Proper sanitation may not eliminate rat populations but often can prevent them from flourishing in high numbers. Repeated increase in rodent population even after the use of poisons is a good indication that habitat modification is needed.

 (Source for information http://www.searo.who.int/entity/emerging_diseases/CDS_faq_Scrub_Typhus.pdf)

Daddy recovered

The late diagnosis had resulted in the failure of internal organs. With systematic treatment and repeated dialysis, he could be revived. He had to be in the hospital for about two weeks. Though he is back home, it will take a few months for him to recover fully to good health.

A few points to note!

Never delay a blood test if the fever continues for more than three days.

Make sure that the patient’s tests are done in a reputed Lab with all facilities.

Don’t think of saving money by going to a small hospital with inadequate facilities. It will be fatal! It was a big mistake that Daddy insisted on getting admitted to a small hospital (advertised by them as speciality hospital) where there were no proper medical assistance.

Never completely trust your medical insurance company! They will promise to give you money and will vanish at the time of billing!

                 © Sibichen K Mathew

An eye on gold

The Prime Minister of India has launched two attractive schemes to use about 20,000 tonnes of the precious metal treasured by residents in their homes for the development of the country. The Gold Monetisation Scheme  and the Sovereign Gold Bonds Scheme  will enable people to earn attractive interest for the gold deposited and for the gold bonds purchased. This is a very laudable initiative to use gold for productive purposes. But what would be the response of the public in this regard?

Image: 22 caratjewellery.blogspot.com

Unlike the citizens of many other countries, the affinity of Indians to gold jewelry has cultural and historical significance. Many are sentimentally attached to their personal jewellery. One incident narrated by an official indicates the emotional bond Indians have with the yellow metal. Income Tax sleuths were busy conducting a raid on a big business man in his residential premises. Officials unearthed huge amounts of cash from the premises. Obviously, the man, who concealed his true income in the income tax returns, had to just sit helplessly while the taxmen sealed the currency in suit cases.  But the hue and cry from the man and his wife started the moment the officials began weighing the gold jewellery in the house. Though the jewellery was worth only about one-hundredth of the cash found, they became very upset when the officials seized those personal ornaments.

 As in many societies and cultures, the life of an Indian centers around a number of familial, social and religious functions. This is irrespective of and usually thrusted upon by his primordial affiliations. In almost all functions, the presence of (or presents of) gold jewellery is inevitable. Even when the child is in the womb of the mother, a ritual called ‘valaikappu’ is performed on the pregnant woman in most of the places. Parents and near relatives adorn her with gold ornaments. Later, after the delivery it is a common tradition to feed the child with gold and honey (within hours of the birth). Gold chain is put on the baby’s waist on the twenty eighth day after the birth. After a few months, the naming ceremony is conducted wherein the child is given new ornaments by the close relatives. It is customary to receive gold jewellery during ceremonies and functions like tonsuring and ear-boring ceremonies, annaprasannam (first meal ceremony), vidyarambham (initiating the child to learning alphabets), upanayanam (sacred thread wearing ceremony among the Brahmin community), puberty ceremony, and marriage. Thus the jewellery has become an important cultural artifact for Indians.

Apart from the above cultural significance attributed to gold, it is also a metal which brings along with it emotional and social security, empowerment and social status, especially for the Indian women. Unlike many other family assets, women hold the role as the custodian of the gold jewellery in many homes. That has made the attempts of many men to dispose of the jewellery not as smooth as in the case of other family assets.

Gold is also a reason for frequent fights between couples and between their families. Gold jewellery takes the form of a villain in many relationships. People make and break marriages in the name of the quantity and quality of gold jewellery.  Many times misery awaited to those daughters who landed in the hands of avaricious in-laws. Relationships in Indian society are embedded with several sovereigns of gold jewellery which in turn defined the nature of reciprocity between people.

It will be a tough task to lure Indian families to part with their gold, even if that means an extra income. Another area of mobilization would be the huge gold treasure of religious trusts and those managed by royal families by giving them attractive interest. Many worship centres receive gold jewellery as offerings from the devotees and the same are kept idle.

 One does not know what prompted Henry Ford to comment that the gold is the most useless thing in the world. Not only the women, the kings and the queens, but also the sovereign governments have an eye on the gold! Nevertheless, it will continue to be a cultural symbol and a source for women empowerment. The new slogan is ‘all that glitters is gold!’

                          (c) Sibichen K Mathew            Views are personal

When God starts staying in your neighborhood

The faithful believe that they have a living God. Some of them look up to the heaven. Some look within. Some wait for the advent. But, what if God comes and stays in your neighborhood?

The crisis of faith most often emerges in a rational mind when doubts arise about the contextual relevance of sermons and scriptures.  For most religious denominations, their creed and the faith are rooted in scriptures that are several centuries old and in events that said to have happened millions of years ago. There could be instances when some of the believers seek from their leaders or explore themselves the contextual interpretation of the writings and oral traditions. Whether it is Adam- Eve, Big-Bang, connection between the microcosm and macrocosm, or any mundane chicken-egg question, the faithful tend to engage in inconclusive debates.

During my sixteen and half hour journey in Rani Chennamma Express Train  to  Kolhapur in Maharashtra state, ‘Joshua’ gave me company. It is a fiction written by Joseph F. Girzon, published by Collier Books (Macmillan, New York) in 1983. That was my second reading of the entire book. Some books do not age. The apt sub title tells it: ‘A Parable for Today’.

It is quite a coincidence to pick up this book to read again on the day media reported with a lot of interest and excitement about Pope Francis’s view on evolution and big-bang. He had said that ‘the scientist must be motivated by the confidence that nature hides, in her evolutionary mechanisms, potentialities for intelligence and freedom to discover and realize, to achieve the development that is in the plan of the creator’. It has always been a challenge for the theists and religious leaders to give divine authenticity for things that happen today. They are asked these questions: What would be God’s view on this? What would God do if he faced such a situation? It needs a lot of courage to admit the truth to the world even if it might be interpreted as a deviation from the existing conclusions.

How is it like if Jesus takes ‘reincarnation’ after 2000 years in this world? What will he do to earn a living? What new gospel would he preach? What would be his attitude towards the religious denominations founded in his name? Will he drive out the people there?   Will he pay a visit to the multitude of churches established in his name and what would be his response to the activities there? What would be his lifestyle? Will he use the modern amenities? What would be the reaction of the people and the authorities? Will they crucify him again or shoot him with a gun?

A poster of the film based on the book

The book ‘Joshua’ is a story about the arrival of a carpenter in the 1980s to a peaceful town with simple people. He taught everyone about the freedom to expand the breadth of inner life. The life was not easy for him though there were many admirers. The book is indeed inspirational and introspective.

Readers get an impression that Joseph F. Girzon wanted to tell his views to the world attributing them to Joshua. A fiction was the easiest and harmless route for that. However the book ‘Joshua’ does not have the flow or style of a good novel. Factually too, the book suffered from several shortcomings. Casual reductionism is very evident while he manifested an oversimplified view of the reality as it existed. One example is his (through Joshua) rejection of the inevitable institutional structure and authority conspicuous in large organized denominations. As a retired catholic priest, Girzon would have known it better.

I found the content thought provoking. The narration could make readers forget the fact that the book is a work of fiction. I fell in love with Joshua just like the way the characters in the fiction viz. Phil, Mary, Charlie, Pat, Herm and many others got infatuated. 

I have jotted down a few of my wishes after reading this book. They are given below:

I wish I could carry a huge cherry log of problems on my shoulders and walk unaware and unconcerned about its weight.

I wish I could notice all those beautiful creations and know how much the Father loves me

I wish I could make my inner life richer and less showy

I wish I could avoid creating human laws to dictate how one can worship the creator

I wish instead of being an expert in law, can I be an expert in love?

I wish I could break my bread and share with a total stranger.

I wish I could make a living just to meet my needs of the day

I wish I understand the fact that 'talent doesn't justify putting on airs and any ability I have comes from my creator, and my recognition of it should make me humble, not arrogant'.

I wish I understand the ' modern unforgivable sin' when I tend to see the 'latest discoveries and creations as reasons to question the very existence of the person who gave them the abilities to discover and create'.

I wish we had leaders who set an example, 'who draw people to God by their own deep faith and by the beauty of their personal lives, not by intimidating people into sterile external observances'.

I wish I tell to myself often that everyone has imperfections as that's the way God made them and “perfection is more a process of striving than a state to be attained"

I wish I could be more humble in my attitude towards those who are less privileged than me

I wish I can lay aside the pettiness and prejudices, even those that have been consecrated through the passing of centuries.

I wish I have more goodness so that I will be chosen to witness better things in this world

An imperfect soul I am, I do not wish to be suppressed by the guilt, threat and fear. Let me be vibrant and joyful to cross the hurdles created by me, accepting the way I am and enjoying the freedom the creator has bestowed.  Then I can be like Joshua: free, simple, courageous, loving and peaceful.

Views are personal                                                     © Sibichen K Mathew