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PT. IBRAHIM AHMAD MEDICAL FOUNDATION, BARAU DIKKO TEACHING HOSPITAL, Kaduna (2025)

13/12/2018

GASTROESOPHAGEAL REFLUX DISEASE
Gastroesophageal reflux disease (GERD) is a chronic stomach acid or, occasionally, stomach content, flws back into your food pipe (esophagus). The backwash (reflux) irritates the lining of your esophagus and causes GERD.
Both acid reflux and heartburn are common digestive conditions that many people experience from time to time. When these signs and symptoms occur at least twice each week or interfere with your daily life, or when your doctor can see damage to your esophagus, you may be diagnosed with GERD.
Most people can manage the discomfort of GERD with lifestyle changes and over-the-counter medications. But some people with GERD may need stronger medications, or even surgery, to reduce symptoms.

SYMPTOMS

GERD signs and symptoms include:
A burning sensation in your chest (heartburn), sometimes spreading to your throat, along with a sour taste in your mouth

Chest pain

Difficulty swallowing (dysphagia)

Dry cough

Hoarseness or sore throat

Regurgitation of food or sour liquid (acid reflux)

Sensation of a lump in your throat

CAUSES

GERD is caused by frequent acid reflux — the backup of stomach acid or bile into the esophagus.

When you swallow, the lower esophageal sphincter — a circular band of muscle around the bottom part of your esophagus — relaxes to allow food and liquid to flow down into your stomach. Then it closes again.

However, if this valve relaxes abnormally or weakens, stomach acid can flow back up into your esophagus, causing frequent heartburn. Sometimes this can disrupt your daily life.

This constant backwash of acid can irritate the lining of your esophagus, causing it to become inflamed (esophagitis). Over time, the inflammation can wear away the esophageal lining, causing complications such as bleeding, esophageal narrowing or Barrett's esophagus (a precancerous condition).

RISK FACTORS
Conditions that can increase your risk of GERD include:

Obesity

Bulging of top of stomach up into the diaphragm (hiatal hernia)

Pregnancy

Smoking

Dry mouth

Asthma

Diabetes

Delayed stomach emptying

Connective tissue disorders, such as scleroderma

COMPLICATIONS
Over time, chronic inflammation in your esophagus can lead to complications, including:

Narrowing of the esophagus (esophageal stricture). Damage to cells in the lower esophagus from acid exposure leads to formation of scar tissue. The scar tissue narrows the food pathway, causing difficulty swallowing.

An open sore in the esophagus (esophageal ulcer). Stomach acid can severely erode tissues in the esophagus, causing an open sore to form. The esophageal ulcer may bleed, cause pain and make swallowing difficult.

Precancerous changes to the esophagus (Barrett's esophagus). In Barrett's esophagus, the tissue lining the lower esophagus changes. These changes are associated with an increased risk of esophageal cancer. The risk of cancer is low, but your doctor will likely recommend regular endoscopy exams to look for early warning signs of esophageal cancer.

TESTS AND DIAGNOSIS

Diagnosis of GERD is based on:

Your symptoms. Your doctor may be able to diagnose GERD based on frequent heartburn and other symptoms.

A test to monitor the amount of acid in your esophagus. Ambulatory acid (pH) probe tests use a device to measure acid for 24 hours. The device identifies when, and for how long, stomach acid regurgitates into your esophagus. One type of monitor is a thin, flexible tube (catheter) that's threaded through your nose into your esophagus. The tube connects to a small computer that you wear around your waist or with a strap over your shoulder.

Another type is a clip that's placed in your esophagus during endoscopy. The probe transmits a signal, also to a small computer that you wear. After about two days, the probe falls off to be passed in your stool. Your doctor may ask that you stop taking GERD medications to prepare for this test.

If you have GERD and you're a candidate for surgery, you may also have other tests, such as:

An X-ray of your upper digestive system. Sometimes called a barium swallow or upper GI series, this procedure involves drinking a chalky liquid that coats and fills the inside lining of your digestive tract. Then X-rays are taken of your upper digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach and upper intestine (duodenum).

A flexible tube to look inside your esophagus. Endoscopy is a way to visually examine the inside of your esophagus and stomach. During endoscopy, your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat.

A test to measure the movement of the esophagus. Esophageal motility testing (manometry) measures movement and pressure in the esophagus. The test involves placing a catheter through your nose and into your esophagus.

TREATMENTS AND DRUGS

Treatment for heartburn and other signs and symptoms of GERD usually begins with over-the-counter medications that control acid. If you don't experience relief within a few weeks, your doctor may recommend other treatments, including medications and surgery.

Initial treatments to control heartburn

Over-the-counter treatments that may help control heartburn include:

Antacids that neutralize stomach acid. Antacids, such as Maalox, Mylanta, Gelusil, Gaviscon, Rolaids and Tums, may provide quick relief. But antacids alone won't heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or constipation.

Medications to reduce acid production. Called H-2-receptor blockers, these medications include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac). H-2-receptor blockers don't act as quickly as antacids do, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions of these medications are available in prescription form.

Medications that block acid production and heal the esophagus. Proton pump inhibitors are stronger blockers of acid production than are H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec, Zegerid OTC).

Contact your doctor if you need to take these medications for longer than two to three weeks or your symptoms are not relieved.

Prescription-strength medications

If heartburn persists despite initial approaches, your doctor may recommend prescription-strength medications, such as:

Prescription-strength H-2-receptor blockers. These include prescription-strength cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid) and ranitidine (Zantac).

Prescription-strength proton pump inhibitors. Prescription-strength proton pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid), pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant).

These medications are generally well-tolerated, but long-term use may be associated with a slight increase in risk of bone fracture and vitamin B-12 deficiency.

Medications to strengthen the lower esophageal sphincter. Baclofen may decrease the frequency of relaxations of the lower esophageal sphincter and therefore decrease gastroesophageal reflux. It has less of an effect than do proton pump inhibitors, but it might be used in severe reflux disease. Baclofen can be associated with significant side effects, most commonly fatigue or confusion.

GERD medications are sometimes combined to increase effectiveness.

Surgery and other procedures used if medications don't help

Most GERD can be controlled through medications. In situations where medications aren't helpful or you wish to avoid long-term medication use, your doctor may recommend more-invasive procedures, such as:

Surgery to reinforce the lower esophageal sphincter (Nissen fundoplication). This surgery involves tightening the lower esophageal sphincter to prevent reflux by wrapping the very top of the stomach around the outside of the lower esophagus. Surgeons usually perform this surgery laparoscopically. In laparoscopic surgery, the surgeon makes three or four small incisions in the abdomen and inserts instruments, including a flexible tube with a tiny camera, through the incisions.

Surgery to strengthen the lower esophageal sphincter (Linx). The Linx device is a ring of tiny magnetic titanium beads that is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the opening between the two closed to refluxing acid, but weak enough so that food can pass through it. It can be implanted using minimally invasive surgery methods. This newer device has been approved by the Food and Drug Administration and early studies with it appear promising.

LIFESTYLE AND HOME REMEDIES

Lifestyle changes may help reduce the frequency of heartburn. Consider trying to:

Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus. If your weight is healthy, work to maintain it. If you are overweight or obese, work to slowly lose weight — no more than 1 or 2 pounds (0.5 to 1 kilogram) a week. Ask your doctor for help in devising a weight-loss strategy that will work for you.

Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.

Avoid foods and drinks that trigger heartburn. Everyone has specific triggers. Common triggers such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine may make heartburn worse. Avoid foods you know will trigger your heartburn.

Eat smaller meals. Avoid overeating by eating smaller meals.

Don't lie down after a meal. Wait at least three hours after eating before lying down or going to bed.

Elevate the head of your bed. If you regularly experience heartburn at night or while trying to sleep, put gravity to work for you. Place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches. If it's not possible to elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Wedges are available at drugstores and medical supply stores. Raising your head with additional pillows is not effective.

Don't smoke. Smoking decreases the lower esophageal sphincter's ability to function properly.

ALTERNATIVE MEDICINE

No alternative medicine therapies have been proved to treat GERD or to reverse damage to the esophagus. Still, some complementary and alternative therapies may provide some relief, when combined with your doctor's care.

Talk to your doctor about what alternative GERD treatments may be safe for you. Options may include:

Herbal remedies. Herbal remedies sometimes used for GERD symptoms include licorice, slippery elm, chamomile, marshmallow and others. Herbal remedies can have serious side effects, and they may interfere with medications. Ask your doctor about a safe dosage before beginning any herbal remedy.

Relaxation therapies. Techniques to calm stress and anxiety may reduce signs and symptoms of GERD. Ask your doctor about relaxation techniques, such as progressive muscle relaxation or guided imagery.

Acupuncture. Acupuncture involves inserting thin needles into specific points on your body. Limited evidence suggests it may help people with heartburn, but major studies have not proved a benefit. Ask your doctor whether acupuncture is safe for you.

04/07/2018

TYPHOID FEVER

DEFINITION

Typhoid fever is caused by Salmonella typhi bacteria. Typhoid fever is rare in industrialized countries. However, it remains a serious health threat in the developing world, especially for children.

Typhoid fever spreads through contaminated food and water or through close contact with someone who's infected. Signs and symptoms usually include high fever, headache, abdominal pain, and either constipation or diarrhea.

When treated with antibiotics, most people with typhoid fever feel better within a few days, although a small percentage of them may die of complications.

Vaccines against typhoid fever are available, but they're only partially effective. Vaccines usually are reserved for those who may be exposed to the disease or are traveling to areas where typhoid fever is common.

SYMPTOMS

Although children with typhoid fever sometimes become sick suddenly, signs and symptoms are more likely to develop gradually — often appearing one to three weeks after exposure to the disease.

1st week of illness

Once signs and symptoms do appear, you're likely to experience:

Fever, that starts low and increases daily, often to as high as 103 or 104 F (39.4 or 40 C)

Headache

Weakness and fatigue

Dry cough

Loss of appetite

Abdominal pain

Diarrhea or constipation

Rash

2nd week of illness

If you don't receive treatment for typhoid fever, you may enter a second stage during which you become very ill and experience:

Continuing high fever

Either diarrhea or severe constipation

Considerable weight loss

Extremely distended abdomen

3rd week of illness

By the third week, you may:

Become delirious

Lie motionless and exhausted with your eyes half-closed in what's known as the typhoid state

Life-threatening complications often develop at this time.

4th week of illness

Improvement may come slowly during the fourth week. Your fever is likely to decrease gradually until your temperature returns to normal in another week to 10 days. But signs and symptoms can return up to two weeks after your fever has subsided.

CAUSES

Typhoid fever is caused by a virulent bacterium called Salmonella typhi. Although they're related, S. typhi and the bacterium responsible for salmonellosis, another serious intestinal infection, aren't the same.

Fecal-oral transmission route

The bacteria that cause typhoid fever spread through contaminated food or water and occasionally through direct contact with someone who is infected. In developing nations, where typhoid is endemic, most cases result from contaminated drinking water and poor sanitation. The majority of people in industrialized countries pick up the typhoid bacteria while traveling and spread it to others through the fecal-oral route.

This means that S. typhi is passed in the f***s and sometimes in the urine of infected people. You can contract the infection if you eat food handled by someone with typhoid fever who hasn't washed carefully after using the toilet. You can also become infected by drinking water contaminated with the bacteria.

Typhoid carriers

Even after treatment with antibiotics, a small number of people who recover from typhoid fever continue to harbor the bacteria in their intestinal tracts or gallbladders, often for years. These people, called chronic carriers, shed the bacteria in their f***s and are capable of infecting others, although they no longer have signs or symptoms of the disease themselves.

RISK FACTORS

Typhoid fever remains a serious worldwide threat — especially in the developing world — affecting an estimated 22 million people each year, according to the Centers for Disease Control and Prevention. The disease is endemic in India, Southeast Asia, Africa, South America and many other areas.

Worldwide, children are at greatest risk of getting the disease, although they generally have milder symptoms than adults do.

If you live in a country where typhoid fever is rare, you're at increased risk if you:

Work in or travel to areas where typhoid fever is endemic

Work as a clinical microbiologist handling Salmonella typhi bacteria

Have close contact with someone who is infected or has recently been infected with typhoid fever

Have an immune system weakened by medications such as corticosteroids or diseases such as HIV/AIDS

Drink water contaminated by sewage that contains S. typhi

COMPLICATIONS

Intestinal bleeding or holes

The most serious complication of typhoid fever — intestinal bleeding or holes (perforations) — may develop in the third week of illness. About 5 percent of people with typhoid fever experience this complication.

Intestinal bleeding is often marked by a sudden drop in blood pressure and shock, followed by the appearance of blood in your stool.

A perforated intestine occurs when your small intestine or large bowel develops a hole, causing intestinal contents to leak into your abdominal cavity and triggering signs and symptoms such as severe abdominal pain, nausea, vomiting and bloodstream infection (sepsis). This life-threatening emergency requires immediate medical care.

Other, less common complications

Other possible complications include:

Inflammation of the heart muscle (myocarditis)

Inflammation of the lining of the heart and valves (endocarditis)

Pneumonia

Inflammation of the pancreas (pancreatitis)

Inflammation of the gallbladder (cholecystitis)

Kidney or bladder infections

Infection and inflammation of the membranes and fluid surrounding your brain and spinal cord (meningitis)

Psychiatric problems such as delirium, hallucinations and paranoid psychosis

With prompt treatment, nearly all people in industrialized nations recover from typhoid. Without treatment, some people may not survive complications of the disease.

TESTS AND DIAGNOSIS

Medical and travel history

Your doctor is likely to suspect typhoid fever based on your symptoms and your medical and travel history. But the diagnosis is usually confirmed by identifying S. typhi in a culture of your blood or other body fluid or tissue.

Body fluid or tissue culture

For the culture, a small sample of your blood, stool, urine or bone marrow is placed on a special medium that encourages the growth of bacteria. In 48 to 72 hours, the culture is checked under a microscope for the presence of typhoid bacteria. A bone marrow culture often is the most sensitive test for S. typhi.

Although performing a culture test is the mainstay for diagnosis, in some instances other testing may be used to confirm a suspected typhoid infection, such as a test to detect antibodies to typhoid bacteria in your blood or a test that checks for typhoid DNA in your blood.

TREATMENTS AND DRUGS

Antibiotic therapy is the only effective treatment for typhoid fever.

Commonly prescribed antibiotics

Ciprofloxacin (Cipro). In the United States, doctors often prescribe this for nonpregnant adults.

Ceftriaxone (Rocephin). This injectable antibiotic is an alternative for women who are pregnant and for children who may not be candidates for ciprofloxacin.

These drugs can cause side effects, and long-term use can lead to the development of antibiotic-resistant strains of bacteria.

Problems with antibiotic resistance

In the past, the drug of choice was chloramphenicol. Doctors no longer commonly use it, however, because of side effects, a high rate of health deterioration after a period of improvement (relapse), and widespread bacterial resistance.

In fact, the existence of antibiotic-resistant bacteria is a growing problem in the treatment of typhoid, especially in the developing world. In recent years, S. typhi also has proved resistant to trimethoprim-sulfamethoxazole and ampicillin.

Supportive therapy

Other treatment steps aimed at managing symptoms include:

Drinking fluids. This helps prevent the dehydration that results from a prolonged fever and diarrhea. If you're severely dehydrated, you may need to receive fluids through a vein in your arm (intravenously).

Eating a healthy diet. Nonbulky, high-calorie meals can help replace the nutrients you lose when you're sick.

LIFESTYLE AND HOME REMEDIES

In many developing nations, the public health goals that can help prevent and control typhoid — safe drinking water, improved sanitation and adequate medical care — may be difficult to achieve. For that reason, some experts believe that vaccinating high-risk populations is the best way to control typhoid fever.

The Centers for Disease Control and Prevention recommends being vaccinated if you''re traveling to areas where the risk of getting typhoid fever is high.

Vaccines

Two vaccines are available.

One is injected in a single dose about two weeks before exposure.

One is given orally in four capsules, with one capsule to be taken every other day.

Neither vaccine is 100 percent effective, and both require repeat immunizations as vaccine effectiveness diminishes over time.

Because the vaccine won't provide complete protection, follow these guidelines when traveling to high-risk areas as well:

Wash your hands. Frequent hand-washing is the best way to control infection. Wash your hands thoroughly with hot, soapy water, especially before eating or preparing food and after using the toilet. Carry an alcohol-based hand sanitizer for times when water isn't available.

Avoid drinking untreated water. Contaminated drinking water is a particular problem in areas where typhoid is endemic. For that reason, drink only bottled water or canned or bottled carbonated beverages, wine and beer. Carbonated bottled water is safer than uncarbonated bottled water is. Wipe the outside of all bottles and cans before you open them. Ask for drinks without ice. Use bottled water to brush your teeth, and try not to swallow water in the shower.

Avoid raw fruits and vegetables. Because raw produce may have been washed in unsafe water, avoid fruits and vegetables that you can't peel, especially lettuce. To be absolutely safe, you may want to avoid raw foods entirely.

Choose hot foods. Avoid food that's stored or served at room temperature. Steaming hot foods are best. And although there's no guarantee that meals served at the finest restaurants are safe, it's best to avoid food from street vendors — it's more likely to be contaminated.

Prevent infecting others

If you're recovering from typhoid, these measures can help keep others safe:

Wash your hands often. This is the single most important thing you can do to keep from spreading the infection to others. Use plenty of hot, soapy water and scrub thoroughly for at least 30 seconds, especially before eating and after using the toilet.

Clean household items daily. Clean toilets, door handles, telephone receivers and water taps at least once a day with a household cleaner and paper towels or disposable cloths.

Avoid handling food. Avoid preparing food for others until your doctor says you're no longer contagious. If you work in the food service industry or a health care facility, you won't be allowed to return to work until tests show that you're no longer shedding typhoid bacteria.

Keep personal items separate. Set aside towels, bed linen and utensils for your own use and wash them frequently in hot, soapy water. Heavily soiled items can be soaked first in disinfectant.

08/04/2018

MALARIA

Definition
Malaria is one of the major public health problems of the country. Around 1.5 million confirmed cases are reported annually by the National Vector Borne Disease Control Programme (NVBDCP), of which 40–50% is due to Plasmodium falciparum. Malaria is curable if effective treatment is started early. Delay in treatment may lead to serious consequences including death. Prompt and effective treatment is also important for controlling the transmission of malaria.

Epidemiology
2 billion people live in areas at risk of malaria transmission in 106 countries and territories.
The World Health Organization estimates that in 2016 malaria caused 216 million clinical episodes and 445,000 deaths.

Types
Parasites of the genus Plasmodium cause malaria. Although there are many species of Plasmodium, only five infect humans and cause malaria.

P. falciparum: Found in tropical and subtropical areas; major contributor to deaths from severe malaria

P. vivax: Found in Asia and Latin America; has a dormant stage that can cause relapses

P. ovale: Found in Africa and the Pacific islands

P. malariae: Worldwide; can cause a chronic infection

P. knowlesi: Found throughout Southeast Asia; can rapidly progress from an uncomplicated case to a severe malaria infection

Parasite life cycle
The life cycle of the falciparum malaria parasite is complex. When an infectious mosquito feeds on a human being, parasites (called sporozoites) are injected into the bloodstream. From here they travel directly to the liver where they mature for about 6 days. At this stage, there are no symptoms of disease in the person who has been infected.

The life cycle of the malarial parasite
Infections begin when the following stages occur:
Sporozoites, the infective stages, are injected by a mosquito and are carried around the body until they invade liver hepatocytes.
Then it undergoes a phase of asexual multiplication (exoerythrocytic schizogony) resulting in the production of many uninucleate merozoites. These merozoites flood out into the blood and invade red blood cells.
They initiate the second phase of asexual multiplication (erythrocytic schizogony) resulting in the production of about 8-16 merozoites which invade new red blood cells.
The infection progresses, some young merozoites develop into male and female gametocytes that circulate in the peripheral blood until they are taken up by a female anopheline mosquito when it feeds.
Within the mosquito the gametocytes mature into male and female gametes, fertilization occurs and a motile zygote (ookinete) is formed within the lumen of the mosquito gut, the beginning of a process known as sporogony. The ookinete penetrates the gut wall and becomes conspicuous oocyst within which another phase of multiplication occurs resulting in the formation of sporozoites that migrate to the salivary glands of a mosquito and are injected when the mosquito feeds on a new host.

Risk factors
Rain and increased water bodies are appropriate for mosquito breeding and disease transmission.
Young children and infants.
Pregnant women.
People with weak immunity are more susceptible to the risk of malaria.
People traveling to malaria-infected areas.
Poverty and lack of health awareness and education contribute to spreading the disease and increasing mortality rate around the world.

Causes
Malaria can occur if a mosquito infected with the Plasmodium parasite bites you. There are four kinds of malaria parasites that can infect humans: Plasmodium vivax, P. ovale, P. malariae, and P. falciparum. P. falciparum causes a more severe form of the disease and those who contract this form of malaria have a higher risk of death. An infected mother can also pass the disease to her baby at birth. This is known as congenital malaria. Malaria is transmitted by blood, so it can also be transmitted through:
An organ transplant
A transfusion
Use of shared needles or syringes

Symptoms
A malaria infection is generally characterized by recurrent attacks with the following signs and symptoms:
Headache
Fever
Shivering
Joint pain
Vomiting
Hemolytic anemia
Jaundice
Hemoglobin in the urine
Retinal damage
Convulsions
Coma
Bloody stools
Abdominal pain
Shaking chills that can range from moderate to severe
High fever
Profuse sweating

Complications
Malaria is a serious illness that can be fatal if not diagnosed and treated quickly. Pregnant women, babies, young children and the elderly are, particularly at risk.
The Plasmodium falciparum parasite causes the most severe malaria symptoms and most deaths.
As complications of severe malaria can occur within hours or days of the first symptoms, it’s important to seek urgent medical help as soon as possible.
Other complications that can arise as a result of severe malaria include:

liver failure and jaundice – yellowing of the skin and whites of the eyes
shock – a sudden drop in blood pressure
pulmonary edema – a build-up of fluid in the lungs
acute respiratory distress syndrome (ARDS)
abnormally low blood sugar – hypoglycemia
kidney failure
swelling and rupturing of the spleen
dehydration

Diagnosis and test
Blood tests can show the presence of the parasite and help tailor treatment by determining:

Whether you have malaria
Which type of malaria parasite is causing your symptoms
If your infection is caused by a parasite resistant to certain drugs
Whether the disease is affecting any of your vital organs
Some blood tests can take several days to complete, while others can produce results in less than 15 minutes.

Treatment and medications
Besides supportive care, the medical team needs to decide on the appropriate antibiotics to treat malaria. The choice will depend on several factors, including

The specific species of parasite identified,
The severity of symptoms, and
Determination of drug resistance based on the geographic area where the patient traveled.
Physicians will administer the medication in pill form or as an intravenous antibiotic depending on above factors.

The most commonly used medications are
Chloroquine (Aralen),
Doxycycline (Vibramycin, Oracea, Adoxa, Atridox),
Quinine (Qualaquin),
Mefloquine (Lariam),
Atovaquone/proguanil (Malarone),
Artemether/lumefantrine (Coartem), and
Primaquine phosphate (Primaquine).

Prevention
Use mosquito repellents regularly – apply it to your skin, especially to all exposed areas, and clothing. For your skin, opt for a repellent that contains at least a 10 percent concentration of DEET.
Use camphor as a repellent- you can light camphor in the room with all the doors and windows closed. Leave it for about 15-20 minutes to keep the mosquitoes away. You can also use the lemon and clove technique- just stick some cloves in a half-sliced lemon and keep it near your bed while you sleep.
Use a mosquito bed net while sleeping.
Wear long-sleeved shirts, pants, and socks.
Wear covered shoes when outside.
Avoid exercising outdoors as mosquitoes get attracted to sweat.
Empty and clean all containers that hold water such as flower pots, flower vases, and animal dishes – at least once a weak – to prevent mosquitoes from breeding at your house.
Keep your surroundings clean, ensuring that there is no stagnant water, which is a breeding ground for the mosquitoes?
Try to stay in air-conditioned or well-screened housing.

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