Lower Secondary Health

101 Topic 1: Nutrients Nutrient needs vary with gender, age, and physical condition. The importance of food and the nutrient needs of individuals in each stage of life and gender are different in nature. Therefore, the amount of nutrients each individual needs varies. 1. Nutrient needs of children It is generally accepted that diet is extremely important for children in terms of physical growth and body movement interaction system development as well as their mental condition and behavior. The key factors contributing to their proper nutritional food intake are as follows: 1. The family who looks after them and acts as a good example. 2. The children themselves who need to be trained. 3. The environment where emulation can occur. We know that children need six categories of nutritious food for their growth and development. There are 3 points to consider about foods for children as follows: 1. Children should obtain a sufficient amount of protein, including milk, eggs, meat, and protein from beans, such as green beans and soy beans. 2. Children should obtain a sufficient amount of energy from foods such as rice, flour, fats and oils. However, soft drinks, sweets, and candies should be limited as they have little nutritional value and may cause dental caries. 3. Vitamins and minerals in foods such as fruits and vegetables which also have fiber, which can help prevent constipation in children.

102 2. Nutrient needs of school-age children With the need for parents to work in todays world, parents or guardians of school-age children may ignore their children’s breakfast which is needed for their bodily growth. This is often a problem for families that need to rush every morning, especially those living in major cities such as Bangkok and the new generation of parents where both parents work and do not have a cook or a maid to provide food for the family in the morning. The present hasty society may cause parents or guardians to ignore their school-age children’s breakfast in spite of the fact that these children are growing. Without breakfast, these children will lose the ability to focus on their studies, have a numb brain and feel drowsy throughout the day. If they go hungry for a long and continuous period of time, it will have a negative effect on their digestive system and cause malnutrition. So, the choice of food school-age children should have for breakfast should be easy to eat and to find such as a box of fresh milk, rice or bread, egg items such as fried eggs, poached eggs, or scrambled eggs, fruits that are easy to find, such as banana, papaya, or orange. With these foods, children will receive adequate nutrition. Parents need to be aware of this issue and pay attention to preparing a nutritious breakfast for their children. 3. Nutrient needs of adolescents Adolescence is a life stage that has tremendous physical growth as well as extreme up-and-down emotional and mental changes. They also have many social, sports, and entertainment activities. Nutrient needs then become higher and both the quantity and quality of their nutrition must be taken into account.

103 The key factors which should be taken into consideration are as follows: 1. Families: Cultivating the habit of eating nutritious food should start at home. Teenagers who are conscious of their appearance may try to restrict their food intake. Therefore, family members should advise them not tolimit nutritious foods that are essential to the body. 2. Teenagers themselves: They are starting to have behavioral changes and are beginning to have their own ideas and opinions. Giving them knowledge about nutrition is necessary to make them aware of the importance of eating nutritious foods on a regular basis which will have a direct impact on them. 3. The environment of the school or educational institutions: Adolescents tend to emulate their peers, both in food consumption and even including taking harmful substances such as alcohol, cigarettes, and drugs. Close monitoring and encouragement for them to do sports or to undertake other beneficial activities will indirectly support good dietary habits. A sufficient amount of protein, energy food, and vitamin intake has to be ensured for all teenagers. The amount of vitamins, especially calcium and iron should also meet the needs of adolescents in different ages. 4. Nutrient needs of adults Even though adults no longer grow larger, their bodies still need complete nutrients to maintain organs and tissues in order to continue to work. One of the key factors to keep adults stong is consuming nutricious food. At older ages, they are working and have more money to spend, usually resulting in over- consumption since they think that eating brings happiness. Some people think that they earn money by putting in a lot of effort, so they must eat expensive foods that are often full of fat. Therefore, the key to control eating habits in adults is to control their body weight. The ideal body weight can be calculated using the formula of body mass index (BMI) as detailed in the topic of weight control. Recommendations for proper dietary intakes in adults are as follows:

104 1. Eat various kinds of food since there is no specific type of food which provides complete nutrition. 2. Eat moderate amounts of food in order to maintain your desired weight. 3. Avoid eating food with too much fat. 4. Eat food with adequate starch and fiber. 5. Avoid food with a lot of sugar. 6. Avoid salty food. 7. If you drink alcohol, drink moderately. 5, Nutrient needs of the elderly The elderly are people over 60 years of age which is currently the age for retirement from public service. In the future there will be more 60-year old people who are healthy in body and in mind with good judgement and decision making ability. The age when one is considered elderly, in general, may therefore shift to 65 years old. For dietary intake or nutrition of people at this age, they should eat food in all categories and control the consumption amount by controlling their weight so as not to gain more weight. In the case of being over- weight, they should lose weight because their structures are deteriorating as they age. If they have to carry more weight, it could cause them problems. Recommendations for food for the elderly are as follows. 1. Protein: The elderly should have quality protein such as eating eggs or drinking at least one glass of milk daily, but should reduce protein intake from meat that usually has fat. 2. Fat: Soy bean oil or corn oil should be used in cooking since they contain linoleic acid.

105 3. Carbohydrates: The elderly should consume less rice and not much sugar. 4. Fiber: The elderly should eat more fiber to help prevent constipation. It is also believed that fiber can help lower the cholesterol level and reduce incidents of colon cancer. 5. Water: The elderly should drink 1 liter of water throughout the day, but this amount can be adjusted according to the needs of the body by observing the urine color. If the urine is pale yellow and almost white, it means there is sufficient water in the body. Alcoholic drinks including tea and coffee should be limited. If their digestion is not functioning properly, it would be better for them to divide their main meals into smaller and more frequent meals with a lesser amount of food at a time. 6. Nutrient needs of pregnant women Pregnant women should ensure that there are 6 major categories of nutrients i.e. protein, carbohydrates, fats, vitamins, minerals, and water in their diet on a regular basis. In addition, they should know which nutrients should be added for the benefit of the fetus as follows: 1. Proteins: include food such as eggs, milk, meat, animal entrails, and dried beans. Pregnant women should eat 1-2 eggs and 1-2 glasses of fresh milk per day. Red meat and sea food which give Iodine should also be consumed. Tofu and soy milk can actually provide as much protein as meat. 2. For energy: eat foods which include rice, flour, sugar, fats and oils,Pregnant women should take a fair amount of rice along with their protein. Vegetable oil such assoybean oil and corn oil should be used for cooking as they contain the necessary fatty acids. Pregnant women should eat around 300 calories of this kind of food per day. 3. Pregnant women need more vitamins and minerals. They should eat fruits such as oranges, papayas, bananas and various vegetables every day to aid defecation. The major minerals that they should eat

106 more of include calcium, phosphorus, magnesium, iron, zinc, and iodine, as well as fat-soluble vitamins, including vitamins A, D, E, K, and water-soluble vitamins such as vitamins B and C. 4. The 9 commandments for healthy eating for Thai people. Our body needs nutrients that are available in various foods in order to have good health. However, we need to know which type of foods we should eat and how much to eat to have sufficient nutrients for the body’s needs. The nine rules of food consumption for the good health of Thai people or the 9 commandments of nutrition can help if you follow them: 1. Eat various kinds of foods in all five categories and watch your body weight. 2. Eat rice as a staple and alternate with other farinaceous foods in some meals. 3. Eat a lot of vegetables and fruits on a regular basis. 4. Eat fish, lean meat, eggs, dried nuts, etc. regularly. 5. Drink milk as appropriate for your age. 6. Eat food with a moderate amount of fat. 7. Avoid eating sweet and salty food. 8. Eat clean and non-contaminated food. 9. Suspend or reduce alcoholic drinks. 5. Antioxidants Cells in the human body produce a type of substance, called free radicals, which destroy the bodies own tissues. These free radicals are the major cause of many health problems including heart disease, cancer, memory loss, etc.

107 Meanwhile, the body deals with free radicals by generating antioxidants into the bloodstreams which are able to eliminate 99.9% of those free radicals, leaving a mere 0.1% to damage cells. This small amount of free radicals manage, however, to cause increasing damage to our cells with the passage of time. When people get older, the body generates less antioxidantsbut it needs them even more for longevity and strong health to fight against diseases which come with old age. Key antioxidants found in food sources are as follows: 1. Beta-carotene which is found in carrots, oranges or yellow vegetables such as tomatoes, pumpkins, and ivy gourds, and dark green vegetables, such as morning glory, choi sum, kale, agasta tips (Sesbania grandiflora), etc. 2. Vitamin C is abundant in guavas, oranges, emblic myrobalans (Phyllanthus emblica), lime, tomatoes and various kinds of vegetables. Kale and cauliflower are very high in vitamin C which can be easily destroyed by heat, humidity and light. 3. Vitamin E is found in rice brans, whole grains, corn, red beans, soy beans, lettuce, sesame, sunflower seeds, rice bran oil, peanut oil, and oils of various other plant seeds. 4. Selenium is found in seafood, meat, and whole grains. The substances in fruits and vegetables have antioxidant properties that can remove the free radicals to reduce harm and prevent cancer. Antioxidants are mostly found in citrus fruits, grapes, and other fresh fruits and vegetables such as garlic and cabbage.

108 Example: Type and quantity of food recommended for daily comsumption of Thai people (between 6 years of age to adults) classified according to energy provision Food group Household measure Energy (kilocalories) 2,400 1,600 2,000 rice – flour 1 ladle = 60 grams or half a measuring cup 8 ladles 10 ladles 12 ladles Vegetables 1 ladle = 40 grams or half a measuring cup 4 (6) ladles 5 ladles 6 ladles Fruit 1 serving = 1 tangerine or 1 Latundan banana 3 (4) 4 servings 5 servings or 4 rambutans servings Meat 1 table spoon = half a mackerel or half an egg 6 table 9 table 12 table or half a chicken thigh spoons spoons spoons Milk 1 glass = 250 cc. 2 (1) 1 glass 1 glass glasses Oil, Sugar, teaspoon As little as needed and Salt Note: The number in ( ) is the recommended quantity for adults.

109 1,600 kilocalories for children aged 6-13 working women aged 25-60 the elderly aged over 60 2,000 kilocalories for male and female teenagers aged 14-25 working people aged 25-60 2,400 kilocalories for men and women using a lot of energy e.g. farmers, laborers, sportsmen Summary Food is a factor of human growth and development. Eating food should be in accordance with nutrition principles to ensure that we have enough energy and get sufficient nutrients. Teenagers are at the age where they are growing and so they should consume proper food according to nutritional principles. Topic2: Cooking to keep the nutritional value in foods 2.1 Methods of hygienic cooking In order to get food that is clean, safe, and has a high nutritional value, the 3 principles of hygienic cooking to be adhered to are Nutrition Values, Well-Cooked, Safe and Clean. Nutrition Values: The cooking methods used should preserve the full value of the food so wash vegetables thoroughly before slicing, and use iodized salt.

110 Well-Cooked: Use heat to cook food well, especially meat, in order to destroy pathogens that it may be contaminated with. The heat used shall be at a high level over a sufficiently long time for the heat to spread to all parts of the food so that all the pathogens are effectively destroyed. Safe and Clean: The quality of food must be thoroughly examined before cooking to ensure that it is clean, safe and meets standards. For example, fresh pork meat must not have signs of Larval tapeworms, fish sauce should have the certification mark from FDA, etc. In addition, the cooking processes should be clean, safe and hygienic, and the food shall be cooked and served by persons who have a good personal hygiene and know how to use proper containers, equipment and food seasonings. For example, they must know how to reduce toxic pesticide residues in fresh vegetables and use only a dedicated spoon for tasting while cooking, etc. 2.2 Methods of preparing food conveniently and quickly Self-cooked food is not only economical but also clean, fresh, tasty and reduces the risk of contamination. However, time is often a constraint for cooking at home. Housewives may prepare some ready-to-cook food during the holidays and store it in the refrigerator so as to be able to cook it quickly while maintaining its nutritional value. Such a preparation should start with meats such as pork, chicken, shrimp and fish which, after having been bought, should be cooked as desired by boiling or quick frying and then divided into portions suitable for each serving before being stored in the refrigerator or in the freezer depending on whether they are to be used the next day or in the days after that. Meat treated in this manner can be used for cooking right away when needed without having to waste time to melt the whole big chunk of raw meat. Simply cut it into appropriate pieces before freezing. This advance preparation not only helps to make cooking more convenient and quick but also helps in maintaining the taste and value of food.

111 2.3 Methods of clean and safe food storage The objective of storing food according to sanitation principles is to extend its value for safe consumption. The key principles for storing food are what may be called the 3S principles, i.e. Specific Space, Suitable Environment and Safe and Clean. Specific Space: Food shall be kept in an organized way according to its type. Each type needs a separate specific space and should not be mixed with other things. There should also be labels or signs to identify each food type. Suitable Envitoment: Food shall be kept by taking into account the environmental conditions suitable for each type of food with regards to temperature and humidity in order to keep it fresh with a longer shelf life. The food environment should be managed so as to prevent contamination. For example, canned food shall be kept in an area with ventilation and at least 30 cm. above ground. Pasteurized milk should be kept at a temperature below 7°C, etc. Safe and Clean: Food shall be kept in a hygienically safe and clean container. The storage area and containers should be cleaned regularly. Food should also not be stored in any container which might have toxic chemical substances. Better to use plastic bags / plastic boxes which are designed for storing food in the refrigerator / freezer. 2.4 The appropriate temperature for microorganism control Microorganisms are generally found in the environment, in humans, animals, food, containers and equipment. They are able to survive in temperatures below 0 degree Celsius to and over 75 degrees Celsius. The bacteria which causedigestive diseases grow well at a room temperature of 25 degrees Celsius to 40 degrees Celsius.

112 In order to destroy microorganisms which cause digestive diseases it is necessary to determine the appropriate range of temperature to ensure that they will be completely destroyed in the food manufacturing process. To destroy pathogens effectively requires a proper temperature in conjunction with an appropriate amount of time, i.e. a very high temperature for a short period of time (121 °C for 1 min) or a lower temperature for a long period of time (63 °C for 30 minutes). Other factors involved in the control of microorganisms include the amount of microorganisms, type of food, pH, and the humidity. For household cooking, the temperature that can destroy bacteria is between 80°C-100°C (the temperature of boiling water) for 15 minutes. For the refrigerator in a temperature of 5-7 degrees Celsius microorganisms can survive and can multiply slowly while at a temperature below 0 degrees Celsius, even though microorganisms can survive they do not multiply. At a temperature of -20 degrees Celsius, microorganisms are definitely eliminated. Hence, for food safety and especially for meat, always cook at a temperature above 80 degrees Celsius to ensure that all of parts will be well cooked while also taking care that the cooked food is clean and safe for consumption. 2.5 The proper temperature for storing fresh meat Fresh meat is a high risk food since there are factors that make it easily perishable, i.e. a high content of organic matter, a high water content, and the proper pH conditions for the growth of bacteria. To keep fresh meat hygienic, it needs to be cleaned and cut or divided into pieces of the appropriate size for each cooking requirement before being packed into clean, separate containers. Fresh meat meant to be used within 24 hours should be kept in the refrigerator with a temperature of between 5 °C and -7 °C. Whereas, the fresh meat to be kept longer (not more than 7 days) must be stored in a freezer with a temperature below 0 °C. Such meat needs to be thawed in a microwave oven prior to its use. If it is to be immersed in cold water instead, the water needs to be changed every 30 minutes to keep the food cool and to ensure that the water used is not a source of contamination by microorganisms which may be damaging.

113 In summary, the proper temperature for keeping fresh meat is the refrigerator’s temperature which is below 7 degrees Celsius if it is to be used within 24 hours, and below 0 degree Celsius (freezing temperature) if it is to be used within 7 days. Even though microbes still exist at such a temperature but they will have a low growth rate or no growth and the prescribed method enables us to keep meat fresh, clean, and safe. 2.6 Importance of the food container The food packaging container is a key factor which is related to exposure to pathogen contamination and chemical substances which are toxic to food. Contamination can occur at every stage from the process of keeping raw food to serving consumers. At the stage of storing raw food, if containers are made of toxic materials or are contaminated, then the food in such a container will also be contaminated. A food container, especially for fresh meat, needs to be cleaned after use before it is reused because it may simply constitute a reservoir of microorganisms. During food preparation, if the container or equipment used for food preparation is contaminated with a toxic chemical, it can also contaminate the cooked food. For example, the use of a colour-coated fishing rack may contaminate the fish being cooked due to the color and lead. In the use of a soft plastic container for storing vinegar, the plastic substances may dissolve and contaminate the vinegar. Therefore, to ensure that the container and equipment used are clean and safe, the important thing is to know how to select and use the container and equipment properly and make sure that they are not made of toxic materials and are suitable for the type of food concerned. It is also important to know how to clean and store the containers and equipment correctly.

114 Topic 3: Consumption values and beliefs Valuez are social beliefs which serve as guidelines for determining appropriate behavior. A value is widely accepted by members of the society who trust it because of the long history behind it as well as the fact that it is shared by all the members of a community. It is their shared feeling about activities and relationships, or the purpose that is important to the well-being of a community. It is what a group of people in a society likes, desires or wants. Nowadays, we often hear that Thai people have the value of using foreign products, imitating foreigners by adopting a lot of international cultural behaviors and forgeting to think about the damaging effects and limitations of such values. The word \"value\" refers to external factors that influence a person's emotions and is derived from learning or any other means which regulate or control the behaviors of people in that society. The success or failure of businesses in marketing depends largely on the compatibility of such business products or services to the group’s social value. Thus, a value is related to our standard response to a stimuli. Individuals will be motivated to engage in behaviors which enable them to realize their value as a consumer and their relationship with the marketing strategy. Each class within society has different values and behaviors in each area of consumption. Some examples of values and behaviors of the Thai people are as follows: 1. Value of wealth and the use of foreign products Prominent points of Thai habits People with this value like to show off ones’ wealth through the use of material products and the products they commonly use are imported.

115 Consumer behaviors People in this group like to use expensive products so that others will see them as being rich. They want others to admire and honour them, to be seen as a leader in their field and like to use imported products only because it is perceived that local products lack in quality and are not up to standard. They feel proud when they use imported products, they like to go abroad shopping for products that sometimes they have no use for. In some cases, they may not have time to travel abroad and have to ask others to buy things for them instead. They are highly in favour of everything that is foreign. They are well dressed from head to toe to enhance their personality and credibility. They like to use credit cards and like convenience, and abhor having to wait. They like socializing with friends who are equally rich but do not like to associate with inferior or poorer people. They think of themselves more than anyone else. Sometimes, they may have financial problems but would be afraid that others may know about their status. So, they tend to rely on loans to support their status and protect their image and do not want anyone to see themselves as poorer than others. Impact of such values This type of people should be encouraged to change for the benefit of society. In particular, the new generation should not be extravagant. Showing off is a bad value. This type of value is harmful to the nation and could be damaging for our country which will become more and more a tributary of foreign countries and it would be difficult for us to recover from such a problem. This kind of value should thus be altered. 2. Value of good health Prominent points of Thai habits People with this value like to take care of their own and their families’ health in order to live longer and healthier.

116 Consumer behaviors Individuals who have the value of good health take care of themselves well. They exercise regularly, like cleanliness, see the doctor regularly, have adequate rest, select valuable foods that are nutritious and useful to the body, as well as take care of the family and wish their families to remain free from disease. They want to live long, have a healthy and strong body, like staying at home and having food at home, are focused on cleanliness, like to watch movies and to listen to music at home. Products that people in this group like to consume include 1. Vegetarian foods 2. Supplementary foods 3. Milk with calcium to strengthen bones 4. Skim milk, yogurt 5. Vitamins such as vitamins C, B, etc. 6. Organic vegetables 7. Fruit juice 8. Mineral water 9. Korean ginseng, Lingzhi mushroom 10. Chicken soup with chinese herbs, black cock soup 11. Medicines (prescribed by doctors) Impact of these values This is a good value which should be promoted because it makes people healthier, helps improve the well-being of their families and makes everyone happier.

117 Persons who have such values Persons with some wealth and people who care about their health. Target group A group of middle-aged people who focus on health and care to be free from illnesses. 3. Value of fun loving Prominent points of Thai habits People in this group love to have fun and merriment all the time, like entertainment and enjoy all festivals. Consumer behaviors The characteristics of these individuals’ behaviors are fun-loving. They like to be merry, to socialize with relatives and friends all the time, to have parties often and celebrate all occasions such as the New Years, Chinese New Year, Songkran festival, etc. Products that people in this group like to consume include 1. All types of foods, either self-cooked food or eating out at restaurants 2. Beverages of all kinds such as soft drinks 3. Various fruits (Thai and imported fruits) 4. Various snacks 5. Alcoholic drinks (made in Thailand and imported) 6. Singing karaoke (at home or at karaoke bars and restaurants) 7. Watching movies 8. Going out for dining and listening to music in hotels, restaurants, cafes

118 9. Going for trips to the countryside to enjoy waterfalls, mountains and the seaside. Impact of such values Individuals with this value should be at least tolerated since they do not cause any harm to society and actually help maintain domestic liquidity as they do not cause money to flow out of the country. Their domestic spending helps to distribute income, promotes spending and generates revenue for communities and tourist attractions. Consequently, more people get employed and the nation’s economic condition is generally improved. 4. Consumerism Prominent points of Thai habits Individuals who love eating but do not care so much about the quality of their comsumption. Consumer behaviors These people have the habit of eating out. They always try find delicious restaurants, no matter how near or how far. If the restaurants are well-known with guarantees from ‚Shell Chuan Chim‛, ‚Mae Choy Nang Ram‛ or ‚Mai Long Mai Roo‛, these people will like to try them whether the food is delicious or not. They like restaurants that look clean, comfortable, with convenient parking lots. Sometimes, they consume too much and such a habit can affect their health and easily cause them to be ill such as having indigestion, diabetes, blood pressure, dyspepsia, food poisoning, etc. Products that people in this group like to consume include 1. Foods of all kinds, especially those in well-known restaurants 2. Fast food, e.g. KFC, McDonalds 3. Japanese restaurants, e.g. Oishi, Fuji 4. Ice cream shops, e.g. Swensens

119 5. Various kinds of snacks 6. Beverages of all kinds 7. Various brands of liquor Impact of such values Individuals with this value may ruin their health since they are not careful about eating. These people should change such a value in order to stay healthy and live longer. If the elderly has this value, it can cause them health problems. For example, they may often experience various ailments and are usually short-lived. Topic 4: Health problems caused by food consumption with poor nutritional value The current hectic lifestyle of people, especially those living in the city, results in a habit of eating foods that are quick and convenientlike fast food, that cause obesity and many other diseases. Therefore, it is important to understand the following key elements regarding food and nutrition. 1) Food refers to edible things which are of benefit to the body. Edible things with no benefit or which may even be harmful to the body such as alcohol and hallucinogenic mushrooms are not called food. 2) Nutrition covers a wider meaning than food. Nutrition refers to any topic relating to food, e.g. classification of food nutrients, benefits of food, digestion, malnutrition, etc. Nutrition is a branch of Applied Sciences that studies the food that we consume for the growth and repair of body parts. 3) A nutrient is a chemical substance which is an important food component. Chemical subtstances derived from nutrients are important and vital to the body because they generate energy and warmth for the body, help in growth and repair the wear and tear of the body to ensure that it is able to function normally. Food analysis shows that it contains various kinds of substances. If classification is made based on nutritional values, foods can be divided into six categories: proteins, carbohydrates, fats, vitamins, minerals and water.

120 4) Energy and Calories Fats, carbohydrates, and proteins benefit the body in a crucial aspect in that it generates energy for the body. In this context, energy is what the body needs, utilizes and collects for the use of internal and external organs of the body. Scientists measure the amount of energy or power obtained from food in a unit of heat called a calorie by defining that 1 calorie is the amount of heat needed to raise the temperature of one gram of water by 1 degree Celsius. In nutrition, the energy derived from 1 calorie of food ingested is the amount of heat needed to raise the temperature of one kilogram of water by 1 degree Celsius. 5) There are 5 main food classes: Food is essential for growth and the nourishment of the body. Some people choose just to eat anything and do not choose to eat any specific kind of nutricious food which is not correct. They should actually consider the nutritional value of food more than how it tastes or if they like or dislike that food. The habit of eating some types of food or not is due to the following reasons: Familiarity: We choose to eat the kind of food we are familiar with or have been eating on a regular basis and do not choose to eat unfamiliar food. Thus, there are a lot of foods that we never eat which we could find to be delicious. Taste or \"deliciousness\" is a reason that leads people to choose their food. Taste varies from one person to another. The same food could be delicious for one person but neutral or not delicious for another. Texture of food: Some people like a crispy food texture and some like soft food texture. Some like to chew sticky meat. In the attitudes of Thai people, family or friends have an influence in their likes or dislikes. For example, in a family where the father does not eat spring onion or coriander and whenever he sees them in any type of food he always picks them out, the children will emulate this habit and not like them as well.

121 So, we should try to change our habits and eat healthy foods that we may never have eaten before based on the consideration of their benefits. Start by tasting and eating a little at a time. Once we have tasted them, we may find that they are not less delicious than our favorite dishes and also that they do not cause us any health problems like the consumption of food with poor nutritional value. Problems from food consumption with poor nutrition include the following: - Malnutrition - Obesity Malnutrition Malnutrition is a condition in which the body does not get a adequate supply of nutrients. It may be caused by lack of food or by food with impaired nutritional content. Food intake, digestion and absorption in the first 2-3 years of life has an effect on the level of intelligence and aptitude to study during later years since it is the period when the brain has the highest growth. The critical period for the body development of children is 3 months after pregnancy until 18-24 months after birth when the myelin sheath of the nervous system is created. The largest proliferation of neurons occurs at the age of 3 years old and affects 80% of the body growth. The physical impact of which can be clearly seen in children suffering from malnutrition who are short, thin, and have wrinkled skin due to the crumpled fat layer of the skin. In addition, their internal organs are affected as follows: 1. Heart: The heart muscle is not strong and has poor muscle movements. 2. Liver: Fat in the liver cells is thin and swollen with water, resulting in poor performance. 3. Kidney: In general, cells have edema and a pale color. 4. Muscle: Cell components are reduced and replaced with water. Besides malnutrition, overfeeding is considered malnutrition as well. It is a condition where excess food is received and the excess energy is converted into choresterol which is affixed to different parts of the body and may spread to blood vessels as well. The consequence is obesity, diabetes, heart disease and other diseases.

122 Assessment of nutritional status: 1. The history of affected children from the hospital to determine the causes of malnutrition. 2. A physical examination to find signs of abnormalities caused by malnutrition and lack of vitamins. Physical examination to evaluate the nutritional status of children is divided into two parts i.e. general physical examination and examination by measuring the body growth. The general physical examination done by a doctor serves as a guide to help assess the condition of the children and the diagnosis on the lack of nutrients and vitamins. The examination by measuring the body growth is a measurement in size of the body, i.e. height and weight which can also give information about the nutrition of children. Being overweight When a person eats any more than the body needs, it results in an over-weight condition which may cause diseases. Diseases caused by being overweight may be fatal or lead to illnesses that require cost and care over a long period of time such as cardiovascular diseases, obesity, etc. Cardiovascular Diseases Cardiovascular diseases constitute a major and top-ranked cause of death for Thai people. Such diseases are associated with changes related to the heart and cardio vessels and also include a variety of other diseases and symptoms such as coronary heart disease, arterioselerosis, and symptoms of high blood pressure. The major disease in this group is the coronary heart disease or coronary artery disease which is the highest cause of mortality among Thai people today.

123 Coronary heart disease This is a disease where the heart arteries are hardened, stenotic, lack flexibility or coronary thrombosis which leads to myocardial ischemia or myocardial infarction. This disease is a major cause of morbidity and has a high mortality rate for Thai people at present and is likely to increase in the future. Causes 1. Genetic factors: People whose parents and grandparents had a coronary artery disease are at a greater risk. If the fat in the arteries is higher than normal, it will cause arteriosclerosis, i.e. the risk of the coronary heart disease. 2. High blood pressure 3. Diabetes: People with diabetes tend to have the coronary artery disease. 4. Obesity and the cardiovascular disease often occur together, especially in people who are fat and have a high cholesterol level. 5. Little or lack of exercise, a blood flow which is not smooth enough and low metabolism can also cause fat to be accumulated. 6. Stress and pressure of life. 7. Smoking: Nicotine and tar from smoking cigarettes can contribute to this disease. In addition to such causes which are variable factors, there may be other risk factors causing the cardiovascular disease as well, such as gender, age, ethnicity, etc. A research study found that males have more risk than females, except for women in their menopause where the estrogen levels drop and those with hypercholesterolemia. As for age, it is found that a much higher incidence of this disease can be found amongst the elderly. And as regards the race, black people are found to have a higher incidence of the disease than white people.

124 Symptoms 1. Intermittent chest pains when stressed or tired which are the initial symptoms. 2. Chest pains with contractions with the pain being felt deeper on the left side from under the ribs to the jaw, the left arm and left-hand fingers for a duration of about 15-20 minutes. The patient may sweat a lot, have nausea, difficulty in breathing or a choking feeling as if mucus was stuck in the throat and a stuffy nose sometimes like having a cold. If the symptoms become severe, the patient will feel dizzy and may faint. Sometimes they feel sleepy and will fall asleep easily. 3. The patient has a throbbing heart or irregular heartbeat. 4. In severe cases, the chest pain is highly severe which is usually caused by a blood clot to the artery stenosis and occlusion, resulting in myocardial infarction. The patient may have a heart attack, shock, cardiac arrest causing sudden death. Prevention 1. If it is known that a family member has a history of this disease, more care should be taken to avoid the relevant risk factors as it may induce the disease. 2. Reduce food with animal oil, coconut milk, palm oil and egg yolk. 3. Avoid eating salty food 4. Reduce starch or carbohydrate foods and eat a lot of fruits and vegetables. 5. Avoid foods with animal fats and sweet food. 6. Exercise regularly. 7. Take enough rest of 6-8 hours per day and find ways to relax. 8. Avoid or stop smoking.

125 Obesity Obesity is a condition where the body accumulates more fat in different parts of the body than normal. The universal principle states that men should not have a body fat of more than 12-15% of the body weight. Women should not have more body fat than 18-20% of the body weight. To be certain whether one has a problem of obesity or not requires a laboratory test. However, learners may assess whether they suffer from obesity simply by comparing their weight and height with the assessment table of the Department of Health. For adults, an assessment can be done by determining the BMI (Body Mass Index) from the following formula: BMI = weight (kilograms) ……………………………………………………… height2 (meters) If the value falls in the range of 18.5-24.9, it is considered as normal – not too fat or too thin. Causes 1. Genetic factors 2. Eating more than what the body needs and having bad eating habits such as eating at irregular times. 3. Lack of exercise. 4. Mental and emotional conditions. Some people tend to eat too much when they are stressed. 5. Side effects from the intake of hormones and some medicines such as oral contraceptive pills, steroids, etc.

126 Symptoms There is a lot of fat in the body, so the body shape is enlarged in size and gains more weight. Prevention 1. Genetic factors: If there is a family history of obesity, more care should be exercized by having appropriate behaviors with regarding obesity. 2. Eat food moderately and select healthy food. Avoid sweets and foods that are high in fat. Have a lot of a variety of vegetables and fruits. 3. Exercise regularly at least three days a week, 30 minutes per day. 4. Find ways to control and manage stress appropriately. Get enough rest. 5. The use of certain medicines may have side effects. It is recommended to see a doctor and to take medicines strictly according to the doctor’s advice. Overall, having proper health care and consumption behavior by \"not spoiling the mouth and mind\" may help prevent obesity without one having to necessarily find ways to lose weight.

127 Lesson 5 Epidemics Main Content Knowledge and understanding of the causes, symptoms, prevention and treatment of communicable diseases that spread quickly and destroy people’s health will enable learners to protect themselves and their family from the diseases and to stop the diseases from spreading to others. This will also contribute to effective national public health measures. Expected learning outcome Learners should be able to: - State the meaning, significance and cause of the spread of diseases. - Explain the causes, symptoms, prevention and treatment of contagious diseases that have become a public health problem. Content scope Topic 1: Meaning, significance and spread of diseases Topic 2: Diseases which are national public health issues

128 Topic 1: Meaning, significance and spread of diseases Meaning and significance Communicable disease is one of the major problems in public health. It causes loss, damages health, and seriously affects the national economy as well. When people are ill, they are not able to study or function normally at work; as a result, they fail to keep up with their studies at school or lose their personal income. Furthermore, a sick person can be a burden to his or her own family because the other members of the family have to spend time to look after the sick and spend money for his or her medical care. At the national level, the country has to spend a large budget on medical care, medical supplies, medical staff and on the construction of hospitals and health centers to provide treatment for the sick. If most people are healthy, this budget can be spent on other projects that are beneficial to the country’s development. Communicable diseases are preventable if everybody realizes the effects and harm that such diseases can cause and are willing to solve and prevent this problem together. 1.1 Meaning of communicable diseases Communicable disease means infectious, transmissible diseases that can spread from one individual to another; it can be transmitted between humans or between humans and animals. The vector of such diseases can be humans, animal, or other things that are contaminated by an infective agent. Epidemics are communicable diseases that can spread very quickly. Some of them take a long time to cure and require treatments that are complicated and expensive. Major epidemics in Thailand that have caused loss of life include malaria, avian influenza (bird flu), SARS, cholera, and H1N1 influenza.

129 Characteristics of communicable diseases 1. The diseases can spread to others very quickly. 2. Spread of the disease is usually caused by people’s behavior or environmental sanitation problems. 3. The diseases cause a high illness rate and are communicable to people of all ages and genders. Communicable diseases that everyone should be aware of and should report if affected There are 14 such diseases, i.e. smallpox, plague, yellow fever, cholera, tetanus neonatorum, diphtheria, polio, rabies, Japanese encephalitis, typhus, anthrax, trichinosis, Meningococcal Meningitis, and yaws (communicable period). 1.2 Types of pathogen There are 5 kinds of pathogens that cause communicable diseases, i.e. bacterium, virus, rickettsia, fungus, and parasite. Bacteria – Bacteria are single-cell organisms and so small that can only be seen through a microscope. They can live in almost any environment. Viruses – Viruses are too small to be seen with the naked eye and must be viewed through an electron microscope. They can be found in the air around us and can cause many diseases such as influenza, measles, smallpox, mumps, dengue fever, chickenpox, etc. Rickettsias – Rickettsias are smaller than bacteria but can be seen through a microscope. They usually co-exist with other living things such as ticks, fleas, louse, round worms, etc. Rickettsias can cause typhus.

130 Fungi – They are considered a plant and can be seen through a microscope. Yeast is a type of fungi that can be used in making bread. However, most types of fungi cause skin diseases such as eczema, chloasma, and tinea pedis. Parasites – They are larger than other types of pathogens. There are both unicellular and multicellular parasites such as dysentery parasite, hookworm, and cestoda. 1.3 Transmission of diseases Diseases can be transmitted in 2 ways: 1. Direct contact: Diseases are transmitted from one host to another without carriers such as through direct physical contact with the infected person or touching his/her saliva, lymph, pus, or blood. 2. Indirect contact: diseases are spread through food, water, or mosquitoes. When a person consumes contaminated food or water or is bitten by a mosquito, the disease is transmitted into the body. How do pathogens enter the body? There are 6 ways that pathogens can enter the body: 1. Respiratory system - When we breathe the pathogen in the air into our body, it can cause diseases such as pneumonia, flu, influenza, tuberculosis, etc. Therefore, it is important to cover our nose and mouth when we cough or sneeze. In addition, diseases can spread to others if we spit saliva or phlegm improperly. 2. Digestive system – Some kinds of pathogen live in food and water, so when we eat or drink such contaminated food and water, the pathogens enter the body and cause communicable diseases such as cholera, dysentery and diarrhea.

131 3. Epidermis – Some kinds of pathogens can enter our body through the skin by the following ways:  Receiving blood or injection such as AIDS, hepatitis B  Touching can transmit eczema and chloasma  Insect bites or stings can cause dengue fever and malaria  Scratches or wounds can give you tetanus  Penetrating the skin such as hookworm 4. Sexual relations –One can contract sexually transmitted diseases such as AIDS by having sexual intercourse with an infected person. 5. Umbilical cord – Diseases that can be transmitted from the mother to the child in the womb through the umbilical cord include syphilis and rubella. 6. Membranes – Some pathogens can enter the body through different membranes like the oral cavity membrane (oral mucosa) or eye membrane (conjunctiva) and cause diseases such as oral thrush and conjunctivitis. Topic 2: Diseases which are national public health issues Transmittable diseases that spread from humans to humans and from animals to humans are the cause of a high rate of illness and mortality. Germs can spread very quickly, from communities to cities and from cities to countries because presently people can travel to faraway places faster and more conveniently through improved transportation systems. The epidemics that are considered a major issue of public health in Thailand include SARS, bird flu, malaria, cholera, chikungunya, influenza, and H1N1 influenza.

132 Severe Acute Respiratory Syndrome (SARS) The first case of SARS occurred in China in November 2002 and started to spread around the world at the beginning of 2003. The World Health Organization (WHO) received reports that there were more than 2,500 people from around 20 countries infected with SARS. Most of the sick people are those who had travelled to SARS-affected areas in the past 10 days before the symptoms were shown or had been close to people suspected to have SARS. The global report of the mortality rate caused by SARS reveals that more than 100 people died of this disease by April 2003. SARS virus - The WHO laboratory found a new kind of virus called ‘corona virus’ in SARS patients. This virus can mutate quickly and today there are more than 19 strains. The mutated virus can cause more or less harm to human health but they can live a very long time in the human body. Incubation period - WHO states that SARS has an incubation period of 2-7 days (not exceeding 10 days). Therefore, suspected SARS patients are quarantined for 10-14 days to observe signs of the disease. Symptoms – The main symptoms of SARS are fever, shaking chills, muscle aches, headache, coughing, and difficulty in breathing. Some other symptoms include diarrhea, wet cough, runny nose, and vomiting. According to WHO’s criteria, suspected SARS patients are those who have the following symptoms: 1. Have fever over 30 degrees Celsius or 100.4 degrees Fahrenheit 2. Cough and have difficulty breathing

133 3. During the 10 days prior to the onset of symptoms, have traveled to or resided in a SARS- affected area or have had close contact with suspected SARS patients However, it does not mean that patients with the above symptoms or having signs of pneumonia or pneumonitis symptoms on their X-ray film must have contracted SARS. Only those who are found infected with corona virus are considered to have contracted SARS. Transmission - SARS can be transmitted through breathing and eating. A study has found that the virus can exist in lymph, stool and urine of patients by the third week after having contracted the disease. Prevention and treatment - A person can contract SARS if respiratory droplets like saliva or phlegm of an infected person get into their mouth or nose. Originally, it was believed that the corona virus could not exist longer than 3 hours outside of the human body but information from recent studies has shown that they can exist longer than 1 day in such a condition or even longer than that in stool or urine. Therefore, the best prevention is frequently washing your hands, strictly following sanitary guidelines and using a protective mask. To protect yourself from SARS, follow the instructions below: 1. Keep your body healthy by eating nutritious food, exercising regularly, getting enough rest, reducing stress, and avoiding all addictive substances. 2. Cover your nose and mouth every time when sneezing or coughing. Use a protective mask when you have a cold. 3. Keep your hand clean by regularly washing them with soap.

134 4. Do not use your hand to rub your eyes or pick your nose and teeth. If you must, then wash your hands before and after doing it. 5. Do not share your towel or handkerchief with others. After using a tissue paper to clean your nose, always dispose of it in a garbage bin with a lid. 6. Use serving spoons when having a meal with others. 7. Keep your house and belongings clean. For example, clean the telephone with cloth dampened with clean water or alcohol. 8. Open doors and windows for good air circulation in the house. 9. When you have a fever and cough, or sneeze, it is advisable to avoid crowded or poorly ventilated areas and to see a physician immediately. 10. Keep your distance from people who cough, or sneeze when you are on public transportation vehicle. 11. Do not have close contact with patients or those who have just travelled from a SARS- affected country. 12. Refrain from or avoid travelling to foreign countries, particularly SARS-affected countries. As for treatment, most SARS patients are given symptomatic treatment and breathing assistance (in case of respiratory failure). Today, a serum extracted from people who have recovered from the disease is given to some SARS patients as an experiment. It was found that the serum is effective if given during the first week of illness. A SARS antiviral drug is being produced for experiments as well. The drug is still under development and will be ready for use in the near future. Malaria

135 Malaria is a communicable disease caused by a protozoan parasite called ‚plasmodium.‛ The vector that carries the disease to humans is the Anopheles mosquito. According to statistics, malaria is a widespread epidemic in the Southern provinces, particularly in the areas with forested mountains and abundant rainfall. Cause – the disease is spread when an Anopheles mosquito bites a person infected with malaria and then bites other people. Symptoms – A person infected with malaria will show symptoms such as dizziness, fatigue, high fever, shaking chills, vomiting, and sweating. In extreme cases, malaria can lead to an impaired function of the brain, seizures, loss of consciousness, and even death. There are also cases of persons infected with malaria that survive the disease but become insane, lose their mind, and have impaired memory. Transmission – Female Anopheles mosquitoes bite and suck malaria-infected blood from a malaria patient and transmit the disease to the other people that they bite. Typically, the parasite stays inside the body and the symptoms will appear after around 10 days of incubation. Prevention 1. Sleep inside a mosquito net to protect yourself from mosquito bites. 2. Eliminate mosquito breeding habitats such as containers with stagnant water. 3. Protect yourself from mosquitoes when going into a forest or an area that has malaria by using a mosquito repellant. 4. If you live in a malaria-infected area, grow citronella grass to repel mosquitoes

136 5. If you suspect you have contracted malaria, get a blood test and receive treatment immediately in order not to spread the disease to others. Treatment Today, some malaria parasites have become resistant to drugs and may cause other serious diseases (such as cerebral malaria). This is more likely to happen with people living in cities as they are not immune to the disease. Therefore, if you have any suspicious symptoms such as a fever after coming back from a forest or malaria-infected area, you should see a physician immediately to find out whether you are infected. Avian Influenza (Bird Flu) Twenty years ago, a new epidemic emerged from a virus called H5N1. The disease is called ‚Bird flu‛ and spread all over the world. In the past, this virus was found naturally only in birds, particularly wild birds and wild ducks which are the disease carriers. The pathogen resides in the intestine of the birds and does not cause any symptoms. The disease is carried around the world as the birds migrate. However, when domestic animals such as chickens, ducks, and pigs receive the virus, 2 types of symptoms can be seen. 1. In less severe cases, the domesticated animals only show mild symptoms which will naturally go away. 2. In severe cases, the domesticated animals will die within 2 days. Bird flu has re-emerged and the disease has spread all over the world. The H5N1 influenza virus spread first amongst farm poultry and was then transmitted to humans, causing such a high

137 rate of mortality that the disease required surveillance. Thus, if a chicken dies of the bird flu, the case must be reported immediately to competent authorities for disease control. In such a case, all the chickens in the area will be eliminated and other protective measures are carried out such as landfills and disinfectant spray to stopthe cycle of the disease before it spreads to humans. Bird flu is a contagious disease amongst birds and poultry and it is not easily transmitted to humans. People most likely to catch the disease are those who have close contact with infected animals. Cause – the disease is caused by the H5N1 virus found in birds which are a natural host of the pathogen. It can be transmitted to other birds and poultry such as farmed chicken, domesticated chicken, fighting cock, and open-farm ducks as well. Incubation period – Incubation period in the human body is 1-8 days. Symptoms – The symptoms are similar to those of seasonal influenza, which include high fever, shaking chills, headache, muscle aches, fatigue, sore throat, and coughing. If the patient is a child, an elderly person, or someone with a chronic disease, the symptoms can be severe and include asthma and breathing difficulty from severe pneumonia. Transmission – The disease can be transmitted by physical contact with sick or dead poultry and birds because the pathogen in the saliva, nasal discharge and fecal droppings of the animal

138 may contaminate the hand of the person and enter the body through nose and eye membranes. People who are at risk of contracting the disease are those who work in poultry farms, slaughterhouses, and people who raise birds and poultry in areas recently affected by the bird flu. Prevention 1. Avoid eating undercooked poultry and eggs, especially during the spread of the disease. 2. When buying raw chickens and eggs, check to make sure that the chickens show no signs of the disease such as dark-colored skin and bleeding spots and that the eggs have no chicken manure on the shell. They should be cleaned before cooking. 3. Do not have close contact or physical contact with birds and poultry, especially those that are sick or dead. andavoid areas with such animals. Avoid touching mucus and the fecal droppings of birds and poultry. 4. Wash yourself and change your clothes after having had close contact with any kind of birds or poultry. 5. Do not eat birds and poultry which died from sickness or unknown causes. 6. Keep your house, workplace, and surrounded areas clean. 7. Get rid of animals that died from disease or abnormal causes by burning or burying them, and disinfect the area with antiseptic or lime.

139 8. Report to the community leader or officials immediately any case of death of an abnormally large number of birds or poultry. Impact of the bird flu epidemic 1. Human-to-human transmission of the bird flu occurs through coughing and sneezing. The disease can spread from an infected person to other people even though the infected person does not show any symptoms. So, it spreads very quickly throughout the world. 2. It is estimated that 25-30 % of the world population will be infected with the disease and about 2-7.4 million people will die from it. If the virus is severe, the mortality rate may become higher. 3. There will be a lack of hospital beds and medical personnel, causing insufficiency of medical services and treatment. 4. There will be a lack of medical supplies, antibiotics, and vaccines for treatment of the disease. 5. There will be adverse social and economic impact on the country.

140 6. International aid may become unavailable or scarce as each nation has to care for its own infected people. Conclusion: How do people catch the bird flu? When wild birds and water birds migrate to a certain area, they will release virus- contaminated bird droppings there. When domesticated animals such as chickens are infected with the virus, the disease can spread to humans as well. People may be infected by the virus if they touch sick chickens and birds or eat them without thoroughly cooking them. In addition, transmission of the bird flu might occur during the process of removing feathers or cleaning the entrails of the chickens as well. H5N1 bird flu is a communicable disease normally found among birds and poultry and does not spread to human easily. If we are careful not to touch dead or infected chicken and always eat chicken meat that has been thoroughly cooked at a temperature not lower than 70 Celsius degree, we will be safe from the disease. Cholera Cholera is an epidemic disease. The primary symptoms of cholera are diarrhea and vomiting, through which the body loses a large amount of water. It is an acute disease of the digestive tract caused by a type of bacteria called Vibrio Cholerae. In general, its symptoms are not severe but around 1 out of 10 patients might get serious diarrhea, vomiting, and leg muscular contraction (cramp). This causes the body to rapidly lose a lot of water and minerals and leads to dehydration and loss of consciousness, or even death if the patient is not treated in time.

141 Transmission and spread of the disease Cholera can be contracted through consumption of food or water contaminated with stool or vomit of an infected person, or by eating raw shellfish from a water source that contains the bacteria. It cannot be transmitted through slight physical contact with an infected person. The spread of this disease often occurs in an area with an inefficient waste management system and insufficient clean water. In recent years, there have been several cholera outbreaks in some regions of Africa, Asia, South America, and Central America. This disease can spread after major natural disasters such as earthquakes or floods. It is important to note that if you practice good food hygiene, the risk of contracting the disease will be low even if you are in an epidemic area. Incubation period The infected person will show symptoms 24 hours to 5 days after infection. On average, the symptoms usually appear 1-2 days after infection. Symptoms 1. In mild cases, the infected person will recover within 1 day or 5 days at the latest. The patient has frequent, watery stools of not more than 1 litre per day. Some adults may also experience stomachache, nausea and vomiting. 2. In severe cases, the infected person has diarrhea, producing a large amount of rather solid stools which later turn into more watery stools containing a lot of mucus and has a strong odor. Sometimes, stools leak out without the patient being aware of it. The diarrhea amounts to about 1 litre of stools per day and will stop in 1-6 days if the patient receives enough water and minerals to compensate for the loss. However, if the body does not receive enough water and minerals in time, the patient will experience severe dehydration and lethargy which makes them unable to move or even sit.

142 Urination decreases. Also, the patient may become unconscious or go into shock, which can be fatal. What to do when you have diarrhea: 1. Avoid strong-flavored or spicy food and preserved food. 2. Drink tea instead of water. In some cases, the patient should not eat any food at all for a period of time to avoid intestinal irritation. 3. Have ORS drinks and boiled water. In the case of small children, a physician should be consulted. 4. In case of severe diarrhea, the patient must be hospitalized immediately. Prevention 1. Eat only freshly-cooked food and drink clean water such as boiled water. Always clean food containers before use. Avoid preserved food, undercooked food, food that is cold, left uncovered or touched by flies. 2. Always clean your hands with soap before meals and cooking as well as after using the toilet. 3. Do not dispose of stools, urine, and waste in water sources or in an improper manner. Waste must be disposed of by burning or burying in the ground in order to prevent the spread of disease. Always defecate and urinate in a toilet. 4. Do not let water get into your mouth when bathing or swimming in a canal or river. 5. Avoid close contact with cholera-infected patients. 6. If infected with the disease, take medicines prescribed by your doctor.

143 Medical treatment Emergency treatment is required for dehydration symptoms. Patients should be provided with water and minerals to compensate for the loss of fluids from diarrhea. Patients suffering severe dehydration should receive intravenous hydration until the level of body water, blood pressure and pulse return to normal. In moderate cases, patients should have an ORS drink. The standard formula of such a drink is 20 grams of glucose, 1.5 grams of potassium, 2.9 grams of trisodium citrate or 2.5 grams of sodium bicarbonate, and 1 litre of clean water. Chikungunya Chikungunya was originally identified in Africa. The disease first occurred in Asia, in Thailand, in 1958, concurrently with the dengue fever outbreak. Professor W McD Hamnon isolated the chikunhunya virus from a patient in a children’s hospital in Bangkok. Characteristics Chikungunya is a viral disease transmitted by Aedes mosquitoes. The symptoms are similar to the dengue fever but there is no plasma leakage from the blood vessel. So, severe symptoms such as shock are not found in Chikungunya patients. Causes The disease is caused by the Chikungunya virus and Aedes mosquitoes are the vector of the disease.

144 Transmission The disease is primarily transmitted by ‚Aedes aegypti‛ mosquitoes. When a female mosquito bites and sucks the blood of an infected person who is currently running a high fever caused by the virus in the blood, the virus will then enter the mosquito's stomach and multiply. When the chikungunya-infected mosquito bites another person, the virus is released into the body of the person and causes the disease. Incubation period The incubation period ranges from 1-12 days, usually 2-3 days. Communicable period The communicable period is the period when the patient has a high fever since a large amount of the virus is in the blood. This is usually within 2-4 days from the infection period. Signs and symptoms The infected person will have acute high fever, rashes on the body that cause an itchy feeling, and conjunctiva injection but without blood spots in the white of the eyes. Generally, the symptoms in children are less severe than those in adults. Joint pain is clearly present in adults, as well as arthritis. It usually occurs at smaller joints such as wrists and ankles. The pain or stiffness will occur in different joints all over the body, moving from one joint to another. Sometimes the pain can be so strong that the patient cannot move the joint at all, but the pain will last only about 1-12 weeks. In some patients, the pain may return in the next few weeks, and in some others, the pain may last for months or years. Unlike dengue fever, there is no record of Chikungunya- infected patients experiencing severe symptoms like a shock. The Chikungunya infection is often found in the rainy season because it is during this time that the mosquito population increases and many cases of disease contraction through Aedes

145 mosquitoes are found. Chikungunya can infect people in every age range, while dengue fever and German measles are mostly found in people younger than 15 years old. There have been 6 Chikungunya outbreaks in Thailand. The first Chikungunya outbreak occurred in Surin in 1988. The second was in 1991, affecting Khon Khaen and Prachinburi. In 1993, there were 3 outbreaks in Lei, Nakhon Srithammarat, and Nong Khai. The disease returned again in 2008. Treatment There is no specific treatment, only supportive treatment such as medicine to reduce fever and joint pain, and rest. Prevention It is similar to the prevention of dengue fever which includes eliminating mosquito breeding habitats, sleeping in a mosquito net or a bedroom with mosquito screens and using a mosquito repellant when visiting a mosquito-infested area. Influenza and H1N1 influenza Influenza Is a viral disease that causes problems to the respiratory system of the body. It can infect both adults and children and is easily transmitted. Its symptoms are more severe than a seasonal cold. The patient will have high fever, headache, muscular aches, fatigue, stuffy nose, runny nose, pink eyes, coughing and sneezing. Some may experience nausea, vomiting, loss of appetite

146 and perhaps develop a complication disease such as bronchitis, acute myocarditis, pneumonia, and tonsillitis. These complications usually occur in small children, elderly people, diabetes patients, heavy smokers and patients with chronic lung diseases. A person infected with influenza should see a doctor because the symptoms will not go away easily like seasonal colds. The patient should have a lot of rest, avoid heavy work or exercise, keep the body warm, avoid taking cold showers, drink a lot of warm water to reduce fever, eat a soft diet, rub the body with a damp cloth to reduce fever, and take prescribed medicines. Prevention of influenza is similar to that of a seasonal cold. Today, an influenza vaccine is available and is highly recommended for elderly people, persons with chronic diseases such as diabetes, asthma, kidney diseases, blood diseases, and lung diseases, HIV patients, children with chronic respiratory problems as well as people who will be visiting other countries and people who work in public service. Influenza is an acute communicable disease that can be transmitted very quickly through the respiratory system. It usually spreads in the rainy season. There are many types of influenza and some of them can be fatal. Causes – It is caused by three kinds of virus, i.e. A, B, and C. Sometimes, the influenza is named according to the city or year in which it is occurred, such as Hong Kong Influenza, 2009 Influenza, etc.

147 Transmission – Similar to that of a seasonal cold, influenza can be transmitted by direct physical contact, coughing, sneezing, or breathing contaminated air. Indirect transmission is also possible if personal belongings and clothes are shared with infected people. Incubation period – It usually ranges from 1-3 days. In children, the communicable period may last longer. Symptoms – Symptoms of influenza are more severe than a seasonal cold and includes headache, chills, fever, muscular pain, fatigue, and loss of appetite. Treatment – There is no specific medicinal treatment, only symptomatic treatment and prevention of complications. Recommended self-care – Treat the disease according to its symptoms, consult a doctor, take prescribed medicines, get a lot of rest, eat nutritious food, keep the body warm by sleeping under a blanket, and cover your mouth and nose when coughing or sneezing to prevent the disease from spreading. Prevention and Control 1. Do not have close contact with patients. Isolate patients. 2. Do not share belongings with a patient. 3. Cover your nose and mouth when coughing or sneezing. 4. Keep the body strong and healthy.

148 H1N1 Influenza or 2009 Influenza This pandemic disease is a current public health issue in Thailand. There have been dozens of deaths caused by the disease and thousands of people have been infected (as of August 2009). The spread of H1N1 influenza has become a global problem. The disease is spreading in Thailand now, especially in schools and offices, and it is possible that the spread will continue at a fast pace. The symptoms of the disease are similar to a seasonal cold and other influenza-like illnesses. Most patients experience mild symptoms and can recover naturally without hospitalization. A small number of people have died from this type of influenza in other countries. Most of them had chronic diseases such as lung diseases, asthma, heart diseases. blood diseases, people with low antibodies, the obese, people older than 65 years old, children younger than 5 years old and pregnant women. The Ministry of Public Health has provided the following guidelines to prevent and control H1N1 influenza. Practical guideline for the general public 1. Regularly clean your hands with water and soap, or an alcohol gel. 2. Do not share glasses, straws, spoons, handkerchiefs, hand towels and body towels with others. 3. Do not have close contact with persons with influenza-like symptoms.

149 4. Keep your body strong by eating nutritious food, drinking a lot of water, having enough rest, and exercising regularly. 5. Avoid crowded places that have poor air circulation or do not stay in such a place longer than necessary. 6. Closely follow other guidelines provided by the Ministry of Public Health. Practical guidelines for seasonal cold and influenza patients 1. If you have mild symptoms such as low fever or do not feel drowsy and are able to eat normally, you can get a symptomatic treatment at home. In such a case, it is not necessary to see a physician. Take Paracetamol tablets to reduce the fever (do not take aspirin), have plenty of rest and drink a lot of water. 2. Do not go to school or work until you have completely recovered. Isolate yourself and do not share personal belongings with others. 3. Use a protective mask when talking or getting close to others. Always cover your mouth and nose with a tissue paper or a handkerchief when coughing or sneezing. 4. Regularly clean your hands with water and soap or alcohol gel, particularly after coughing or sneezing. 5. If you experience severe symptoms such as breathing difficulty, shortness of breath, frequent vomiting, and drowsiness, consult a physician immediately.

150 Practical guidelines for schools and educational institutions 1. Advise students having influenza-like symptoms to rest at home or at the dormitory. If they have severe symptoms, advise them to consult a physician. 2. Check the number of absent students every day. If the number of absent students is abnormally high or there are 3 students or more in the same class who are absent on the same day and they are suspected to have contracted influenza, inform the local public health officer for investigation and disease control. 3. Advise students who have just returned from abroad to monitor their own health for 7 days as well as to stay at home if they have signs of illness. 4. If appropriate, schools and educational institutions should instruct students who have influenza-like symptoms to stay home in order to prevent the disease from spreading. It is not necessary to close the school or institution. However, the matter of whether to continue normal operations should be discussed with local public health officers. 5. Clean all public equipment, materials and tools shared by many users, such as student desks, door knobs, telephones, handrails, computers, etc., with water mixed with some detergent at least once or twice a day. Ensure that there are sufficient washbasins, soap, and water. Open the windows and doors of class rooms from time to time to allow the air to circulate and let the sunlight in.