Which of the following statements best describes contagious disease?a) Diseases that can easily be acquired b) Diseases that requires direct transmission/inoculation c) Diseases that caused exclusively by bacteria d) Diseases that requires vectors for transmission Definition of Terms Communicable disease An illness due to infectious agents or its toxic products which is transmitted directly or indirectly to all person or animal or through an agency of an intermediate animal host, vector of the inanimate environment. Contagious Applied to disease that are easily spread directly transmitted from person to person or from reservoir. Infectious Are those diseases not transmitted by ordinary contact but require a direct inoculation through a break in the previously intact skin or mucous membrane. N.B. All contagious diseases are communicable and infectious but not all communicable and infectious diseases are necessarily contagious Infection Invasion or multiplication of microorganism on the tissues of the host. Inflammation A non-specific reaction that is immediate and provides short-term protection Incubation period Time interval between the first exposure to the disease of the susceptible person or animal and the appearance of the first S/Sx of the disease. Period of communicability Period where the infecting microorganism is capable of infecting another host. Pathognomonic S/Sx pointing out the nature of a specific disease. Prodromal Premonitory or early sign indicating an impending attack of the disease. Direct transmission Pathogens infect the host by body contact. Indirect transmission Occurs through an intermediate host; a vector or inanimate object. Epidemiology Study of the occurrence, distribution, and control of infectious and non-infectious diseases in populations. Rabies infection is a disease that cause hydrophobia. Epidemiologically speaking, it is considered as what? Epidemic Endemic Pandemic sporadic Epidemic A sudden outbreak of infectious disease that spreads rapidly through the population, affecting a large proportion of people. Endemic Occurring frequently in a particular region population; disease is continuously present. or Pandemic Disease with worldwide occurrence Sporadic Disease occurring at random intervals CHAIN OF INFECTION 1. Causative agent a. b. c. d. e. Bacteria Viruses Fungi Protozoa Parasites 2. Reservior Natural habitat of the organism that is where it resides and multiplies 3. 4. Portal of Exit Mode of Transmission Corresponds to the way organism infect a host Contact transmission Vehicle route Airborne transmission Vector-borne 5. 6. Portal of Entry Susceptible host ISOLATION the separation of persons suffering from communicable disease or carriers of the infecting organism from other person, and placing them such under conditions that direct or indirect transmission to susceptible person is prevented. Standard Precautions Focused on the use of protective barrier in order to interrupt transmission and break the chain of infection. Transmission Based Precaution Designed for patients documented or suspected to be infected/colonized with highly transmissible or epidemiologically important pathogens. TRANSMISSION BASED PRECAUTION Airborne Precautions Transmission occurs by dissemination of either airborne nuclei or dust particles containing the infectious agent Dispersed through air currents and inhaled and deposited on susceptible host (e.g. Mycobacterium Tuberculosis) Droplet Precautions Transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large particle droplets containing microorganism Contact Direct precautions contact- involves skin-to-skin contact and physical transfer of microorganisms. Indirect contact- involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient’s environment. Complete Quarantine QUARANTINE the limitation of freedom of movement of persons exposed to communicable disease during the longest incubation period. Modified Quarantine selective, partial limitation of freedom of movement determined on the danger of the disease transmission. Surveillance practice of close supervision of contacts without restriction of their movement. Segregation separation for special consideration, control of observation of some part of a group of persons from others. DISINFECTION Killing of pathogenic agents by physical or chemical means. Types: Terminal process of rendering personal clothing and immediate physical environment of the patient free from the possibility of conveying the infection to others at the time when the patient is no longer a source of infection. Concurrent disinfection after the discharge of infectious material from the body of infected person. IMMUNIZATION Is the induction or introduction of specific protective antibodies in a susceptible person or animal, or the production of cellular immunity in such person or animal. Immunity The ability of the body to protect itself from pathogenic organisms Types of Immunity Natural Immunity - genetically acquired immunity; exist without prior exposure to an immunologically active substance Acquired Immunity - a response that developed during the course of person’s lifetime. Classification of Acquired Immunity Active immunity- results when the body produces it’s own antibodies in response to an antigen Natural Acquired Active- results from having the disease Artificially Acquired Active- conferred with immunization with an antigen Passive immunity- results when the antibody is transferred artificially Artificially Acquired Passive- antibodies transferred from sensitized person Natural Acquired Passive- antibodies obtained through placenta or breastmilk IMMUNITY/RESISTANCE Natural Artificial Passive Passive Antitoxin Antiserum Convalescent Gamma Globulin Placental Transfer Active Subclinical Immunization Recovery from disease Active Vaccine Toxoid Diptheria Tetanus THE 7 TARGET DISEASES Poliomyelitis Measles Diphtheria Pertussis Tetanus Tuberculosis Hepatitis B . A child comes to the hospital after exposure to diphtheria and is given an antitoxin. This type of immunity is called as: active natural immunity active artificial immunity passive natural immunity passive artificial immunity PART I COMMUNICABLE DISEASES ACQUIRED THROUGH RESPIRATORY TRACT A . PULMONARY TUBERCULOSIS Consumption, Phthisis In the Philippines, ranked tenth in the leading cause of morbidity (2002) and ranked 6th in mortality (2002). 75 Filipinos die everyday of the disease According to WHO: 8-10 million new cases with new strain of TB Causative Agent: Mycobacterium Tuberculosis (Acid-Fast aerobic organism) Mode of Transmission: Airborne From adult-to-child and not vice versa nor from child-to-child Incubation Period: 2-10 weeks Period of Communicability: as long as viable tubercle are being discharged in the sputum CLINICAL MANIFESTATIONS Early S/Sx Late signs (non-specific symptoms) Coughing (mucoid or mucopurulent sputum) Low grade fever (afternoon) Crepitant rales (crackling Body malaise sounds) Anorexia Chest pain Weight loss Hemoptysis Night sweats DIAGNOSTIC PROCEDURES CXR- determines the extent and location of the infection Sputum Smear and Culture Tuberculin Test (Mantoux test) Consist of intradermal injection of 2 tuberculin units of Purified Protien Derivative (PPD) Injected at the volar surface of the forearm to form a wheel measuring 57 mm in diameter The test should be read 48-72 hours later noting the size of the induration Positive reaction- 10 mm or more Vaccination: Bacilli Calmette Guerin (BCG) TREATMENT REGIMEN AND CATEGORY Rifampicin Isoniazid 450 mg 300 mg Pyrazinamide Ethambutol 500 mg 400 mg (not given to children < 6 y/o) Streptomycin SO4 1 gm (not given to pregnant women) Category 1 New PTB whose sputum is positive Seriously ill pts. with severe forms of: Smear negative PTB with extensive parenchymal involvement Extra PTB Category 2 For previously treated patient who are Relapses and Failures Category 3 New PTB whose sputum is negative for 3 times and a CXR result of PTB minimal Extra-PTB (not serious) SUMMARY TABLE FOR TREATMENT FOR 30-50 KG BW Category and Treatment Category 1* Intensive Phase RIPE (2 mos) >50 kg: add PZA 500 mg INH 100 mg Ethambutol 400 mg Maintenance Phase RI (4 mos) Category 2 RIPES (Intensive 1 for 2 mos) RIPE (Intensive 2 for 1 mo) >50 kg: add PZA 500 mg INH 100 mg Ethambutol 400 mg RIE (5 mos) Category 3 RIP (2 mos) >50 kg: add PZA 500 mg INH 100 mg RI (2 mos) MANAGEMENT Isolate patient properly Emphasize the importance of bed rest Meticulous skin care Adequate oral hygiene Emphasize high CHON diet with liberal amount of fats, Vitamins A and C should be prescribed Teach patient on medication compliance Weigh patient regularly Educate patient to control propagation of secretions while coughing (cover the mouth and nose with double ply tissue when coughing/sneezing) B. MENINGOCOCCAL INFECTIONS Acute Meningococcemia (with or without Meningitis) It usually starts as a nasopharyngitis followed by sudden onset of high fever with chills, N/V, malaise and headache Petechial, purpuric or ecchymotic hemorrhages scattered all over the entire body surface appear Histologically, the skin lesions are the results of acute vasculitis in the minute vessels followed by suppurative necrosis and hemorrhage into the dermal connective tissue. Marked perivascular cuffing of neutrophils and macrophages with lymphocytes are seen The adrenal lesions starts as bleeding into the medulla which extends to the cortex Causative Agents Neisseria meningitidis (encapsulated gram-negative diplococcus) Mode of Transmission Respiratory droplets shed from the upper respiratory tract Salivary contact Incubation Period 3-4 days, but can vary from 2-7 days Period of Communicability Until the organisms are no longer present in discharges from the nose and mouth. The combination of meningococcemia and adrenal medullary hemorrhage is known as the WATERHOUSE FRIEDERICHSEN SYNDROME (rapid dev’t of the petechia to purpura and ecchymotic spots in asso. with shock) Treatment Penicillin- as the current drug of choice Chloramphenicol- alternative choice Ciprofloxacin Ceftriaxone RECOMMENDED PROPHYLAXIS REGIMENS Age Rifampicin ≤ 1 month Dose 5 mg/kg, PO q 12 hr Duration 2 days Precautions May interfere with oral contraceptives, seizure prevention and anti-coagulants; may stain soft contact lenses To decrease pain at injection site, dilute with 1% lidocaine Not recommended for < 18 y/o > 1 month Ceftriaxone ≤ 15 years ≥ 15 years Ciprofloxacin ≥ 18 years 10mg/kg PO (max. 600 mg) 125 mg IM 250 mg IM 500 mg PO 2 days Single dose Single dose Single dose BACTERIAL MENINGITIS is an inflammation of the meninges or covering of the brain and spinal cord Causative Agents Meningococcus (Neisseria meningitides) Pnuemococcus (Streptococcus Pneumoniae) Staphylococcus Hemophilus influenzae Enteric organisms (Salmonella, E. coli, Psuedomonas, etc) Respiratory droplets Direct contact Variable, 1-10 days (majority of cases from 3-6 days) For 24 hours after the start of effective antibiotic treatment Mode of Transmission Incubation Period Period of Communicability CLINICAL MANIFESTATIONS Headache, prostration, chills, fever, N/V, back pain, stiff neck Generalized seizures/convulsions (occurs in approx. 10-80 %) Blurring of vision Alteration of sensorium Petechial or hemorrhagic rash may develop Pulse and respiratory rates are increased Opisthotonus Nuchal rigidity Brudzinski’s sign Kernig’s sign Diagnostics Lumbar puncture for CSF examination Increased ICP (normal 5-15 mmHg or 60-180 mm H2O) Fluid is turbid/purulent (>1000cc/mm)predominantly polymorphonuclear leukocytes Elevated CSF CHON (>100 mg/dL) Decreased CSF glucose (40 mg/dL) Presence of causative agents in gram-stained smears (Countercurrent Immunoelectrophoresis) Treatment Antibiotics Ampicillin Chloramphenicol Sulfonamide Penicillin Reduction of ICP IV fluids and electrolytes, blood, plasma or plasma expanders for dehydration and shock Anti-convulsants Cuffed Endotracheal/tracheostomy- to provide a patent airway MANAGEMENT Maintain strict surgical aseptic technique when doing dressings or lumbar puncture Isolate the patient Wash hands before and after touching/caring the patient Wear gown and mask when caring/touching the patient Change positions q 2 hours Protect eyes from bright light Check for signs of dehydrations Proper disposal of secretions Emphasize the importance of masking Maintain side rails up Keep patient quiet in darkened room and at complete physical rest Monitor I and O carefully C. DIPHTHERIA Is an infectious disease characterized by the formation of the psuedomembrane commonly in the face area and tonsils, and the elaboration of a powerful exotoxins affecting the important viscera of the heart and kidneys and the peripheral nervous system. Higher prevalence occurring in cooler months (December- February) Causative Agent: Corynebacterium diphtheriae (KlebsLoffler bacillus) Mode of Transmission Direct contact with patients or carriers with discharges from the respiratory tract or saliva Indirect contact through various articles Incubation Period: 2-6 days, occasionally longer Period of Communicability: variable; 2-4 weeks in untreated pts; 1-2 days in treated patients Vaccination: DPT CLINICAL MANIFESTATIONS Nasal Diphtheria Irritating, bloody discharges with excoriated nares and upper lip Pseudomembrane in nasal septum (pathognomonic sign) Fever Cervical or submaxillary glands enlargement Nose almost completely stopped up Sore throat Psuedomembrane on throat and uvula Fever Tonsillitis with exudative membrane Redness and warmth Bull neck appearance Hoarseness of voice Initiative ―croupy‖ cough Cyanosis Profuse perspiration DOB Pharyngeal Diphtheria Laryngeal diphtheria DIAGNOSTICS Nose and Throat culture There must be 3 negative results Schick’s test- determines the susceptibility and immunity to diphtheria intradermal injection of dilute diphtheria toxins (0.1cc) within 48-72 hours a positive reaction reveals itself as a local circumscribed area of redness, usually 1-3 cm in diameter but occasionally larger Moloney’s test- determine hypersensitivity to diphtheria anti-toxin intradermal injection of 0.1 cc of diphtheria toxoid if positive, an area of erythema will develop within 24 hours of injection MANAGEMENT Administer anti-diphtheria to neutralize toxins skin testing is required before administering antitoxin to determine allergic reactions Administer Epinephrine, corticosteroids, and Penicillin CBR (at least 2 weeks) Small frequent feedings Provide liquid or soft diet with minimal CHON requirement and sufficient CHO Maintain patent airway Monitor fluid I & O Throat irrigation to ease the pain and clear the throat of mucus and fragments of membranes Apply ice collar to reduce pain of sore throat D. PERTUSSIS (WHOOPING COUGH) characterized by repeated attacks of spasmodic coughing which consists of a series of explosive expirations, typically ending in a long drawn force inspiration which produces the sound ―whoop‖ and usually followed by vomiting. Causative Agent: Bordetella Pertussis (Bordet Gengou Bacillus) Mode of Transmission: Direct contact or droplet from respiratory and salivary secretions Incubation Period: 7-14 days, but not exceeding 21 days Period of Communicability: from 7 days after the exposure to 3 weeks after typical paroxysms. Vaccination: DPT Diagnostics: Bordet Gengou test or Agar plate CLINICAL MANIFESTATIONS Catarrhal or Invasive Stage (7-14 days) Fever, watery eyes, sneezing Cough is worse at night (slight, dry, irritative restlessness Spasmodic or Paroxysmal Stage (4-6 weeks) Pathognomonic sign: The cough occurs in a series of 5-10 explosive rapid cough in one expiration ending in a sudden noisy inspiration asso with a long, kigh-pitched crowing sound or ―whoop‖, usually provoked by crying, eating, drinking, or physical exertion During the attack the child becomes cyanotic, the eyes appears to bulge and tongue protrudes Swollen head and neck veins Abdominal hernia Convalescent stage - symptoms subsides MANAGEMENT Provide a quiet and non-stimulating environment CBR Keep patient warm and out of drafts or wind Mouth and nose must be kept clean Small frequent feedings to avoid vomiting A light but nutritious diet with plenty of fruit juices but no seasoned foods Fluids given between meals Apply abdominal binder Administer Erythromycin or ampicillin E. PNUEMONIA Is an inflammation of the lungs associated with exudates in the alveolar lumen It refers to the consolidation or solidification of the air sacs with the inflammatory exudates. Causative Agents Streptococcus pnuemoniae (most common) Hemophilus Influenzae Staphylococcus aureus Klebsiellae pneumonia (Fried Lander’s bacillus) Psuedomonas Aeruginosa Legionella pneumonia (Legionnaire’s Disease) Mycoplasma Pnuemonia Viral Lipid Chemical Mode of transmission: Droplet infection Indirect contact Incubation Period: 1-3 days Diagnostics sputum smears and cultures dull percussion on the affected side CXR CLINICAL MANIFESTATIONS sudden onset of shaking chills (young children) rhinitis/common cold rapidly rising fever chest indrawing stabbing chest pain aggravated by respiration and coughing paroxysmal or choking cough, productive in nature pain in the abdomen herpes appears on lips sputum- little bright red/rusty or prune juice colored sputum convulsions and vomiting in children flushed face, cyanosis dilated pupils body malaise marked tachypnea with respiratory grunting and flaring of nares pulse is rapid and bounding anxiety MANAGEMENT Absolute bedrest Insurance of adequate salt, fluid, calorie, and vitamin intake, avoid gas-forming foods Keep the patient warm especially in the lower extremities Do back rubbing for easy aid in respiration and easy expectoration of sputum Do bronchial tapping and position the patient in side lying position with the head lowered than the trunk Elevate the head and shoulders with pillows often to relieve labored breathing and to lessen coughing Instruct patient to have adequate intake of fluids Measure I and O Teach and supervise effective coughing, turning and deep breathing technique for easy ventilation and aid in respiration Administer expectorants and bronchodilators Administer antibiotics (pen G for 7-10 days) F. MEASLES (RUBEOLA, MORBILLI, 7 DAY MEASLES, HARD MEASLES, RED MEASLES) is a contagious exanthematous disease of acute onset most often affects children and the chief symptoms is referable to upper respiratory tracts. Causative Agent: Filtrable virus (Morbillivirus)- Genus Paramyxovirus- Family Incubation Period: 10-12 days; 8 days-shortest, 20 days- longest Mode of Transmission: Direct contact with nasal secretions and infected person Indirect contact through articles Droplet spread Period of Communicablity: stage) 7 days before-5 days after the rash (during cold Pathognomonic Sign: Koplik’s spot--lesions at mucosa of the inner cheek (1-2 days before measles rash) CLINICAL MANIFESTATIONS Pre-eruptive or stage of invasion (3-6 days) Pt is highly communicable Fever Catarrhal symptoms (rhinitis, conjunctivitis, photophobia, coryza) Cough that persist up to convalescent Koplik’s spot Stimson’s line- transverse line of inflammation along the margin of the eyelid Eruptive stage Maculo-papular rash (fully developed at 2nd day) Appears first to the bridge of the nose and hairline, forehead, face, behind the earlobe, to the side of the neck, then on the trunk and finally to the extremities Rashes are hot to touch, dry, and slightly elevated High fever (40-41 degree celcius) Anorexia and irritability Diarrhea, pruritus, lethargy and occipital lymphadenopathy Sore throat Convalescence/Desquamation stage Rashes fade away in a manner of eruption Diagnostics Nose and throat swabs Urinalysis- obtained 4 days after the onset of eruptions CBC- leucopenia Immunization Naturally acquired active- after getting infected confers a life-long immunity Naturally acquired passive- infants under 6 mos usually acquire immunity through transplacental immunity Anti-Measles @ 9 months MMR (15 months-11-12 y/o) not given to pregnant, active TB, leukemia, lymphoma, decrease immune system MANAGEMENT provide isolation meticulous skin care --warm alcohol rub good oral and nasal hygiene proper care of the eyes -- use vaseline to prevent lids sticking together dimlight, advise to wear dark eye glasses no salicylates administer anti-viral medication (Isoprenosine) G. GERMAN MEASLES (RUBELLA, 3 DAY MEASLES) acute infectious disease characterized by mild constitutional symptoms, rose colored macular eruption which may resembles measles it has a teratogenic effect to the fetus on the first trimester Causative Agent: Rubella Virus (Myxovirus) Incubation Period: 10-21 days Mode of Transmission: Direct contact, droplets, placental transmission Period of Communicability: 7 days before-5 days after the rash CLINICAL MANIFESTATIONS Prodromal period (3-5 days) Low grade fever, headache, malaise, coryza, conjunctivitis, lymphadenopathy Macular rash- begins on the face-neck-trunk and limbs; leaves no pigmentation or desquamation Eruptive period Forchheimer’s spot (pinkish rash on the soft palate Splenomegaly Testicular pain, transient polyarthralgia and polyarthritis in adults Diagnostics Rubella hemaglutination Live Attenuated Rubella Vaccines (1 year to puberty) Vaccination Management Isolation, bed rest for the first few days Meticulous skin care, good oral and nasal hygiene (use petroleum jelly if lips become dry) Increase fluid intake H. VARICELLA (CHICKEN POX) a highly exanthematous disease characterized by marked appearance of vesicular eruptions on the skin and mucous membranes and leaves granular scabs. Causative Agent: Varicella Zooster virus – DNA containing virus Incubation Period: 10-21 days Mode of transmission Direct contact Indirect contact Droplet infection Period of Communicability: from start of fever until last vesicle is dry Clinical manifestation Mild fever, malaise and muscle pain Rash: macule—papules—vesicle—pustule—crust (starts on trunk to face and to extremities) Intense pruritus Immunity contacting the disease gives a lifelong immunity, remains in the body’s nerve cells- Shingles MANAGEMENT Isolate patient in a room by itself Provide a well-ventilated, warm room Warm baths daily, to relieve itching Calamine lotion and hydrocortisone lotion for itching Avoid injuring the lesions and should be patted dry Maintain good oral hygiene Administer zoverax , oral acyclovir, or immunosin(anti-virals) Administer penicillin- when the crust are severe or infected I. INFLUENZA (LA GRIPPE, FLU) acute highly communicable and self-limiting disease characterized by abrupt onset with fever which last 1-6 days, chilly sensation or chills, aches or pains in the back and limbs with prostration. Causative Agent: Influenza Virus A, B, C Incubation Period: 24-72 hours Mode of Transmission: direct contact, airborne and droplet route Period of Communicability: Until 5th day of the disease Clinical Manifestations Chilly sensations or convulsions Hyperpyrexia Malaise, sorethroat Coryza, rhinorrhea, myalgia, and headache Slow PR, increase RR, and sweating Hacking cough, moist rales MANAGEMENT Isolation of the patient Limit activity and maintain bed rest Maintenance of good nutrition, encourage diet rich in vitamins and minerals Encourage liberal fluid intake Amantadine Hcl- prophylactic treatment of Influenza A Administer analgesics and antipyretics Offer cough syrup J. MUMPS (EPIDEMIC PAROTITIS) an acute contagious disease characterized by swelling of one or both of the parotid glands, usually occurring in epidemic form. Causative Agent: Filterable Virus- of the paramyxovirus group (RNA- containing Virus) Incubation Period: 12-26 days, usually 18 days Mode of Transmission: direct contact; droplet, or airborne infection Period of Communicability: 7 days before – 9 days after parotid glands swell Clinical Manifestations Painful swelling in front of ear, angle of jaws and down the neck Fever Malaise Loss of appetite Swelling of one or both testicles (orchitis) Oophoritis (Female) Diagnostics Viral culture Serum Amylase Vaccination: MMR Management Isolation (private room) Absolute bed rest at least 4 days. Advise male to ear well fitting support Hot and cold compress Bland diet Administer anti-viral medication K. SARS Causative Agent: Human Corona Virus Incubation period: 2-7 days Mode of Transmission: direct contact, droplet infection, likely through oral-fecal route Clinical manifestations Prodrome of fever Chills and rigor Headache, malaise, myalgias Lower respiratory signs and symptoms includes: Non-productive cough Dyspnea Hypoxemia Focal infiltrate to patchy, interstitial infiltrates later consolidation Leucopenia, thrombocytopenia MANAGEMENT Isolation Aerolization Chest physiotherapy Administer Rebavirin and other antibiotics Administer steroids PART II COMMUNICABLE DISEASES ACQUIRED THROUGH GASTRO-INTESTINAL TRACT A. THYPHOID FEVER (ENTERIC FEVER, TYPHUS) is a general infection involving primarily the lymphoid tissue (Peyer’s Patches) of the small intestines. It occurs anytime of the year but especially from May-August Causative Agent: Salmonella Typhi/Typhosa The agent is gram negative, motile and non-sporeforming bacillus The organism is pathogenic only for men Incubation Period: 5-40 days Period of Communicability: as long as the bacteria is excreted Mode of Transmission: Fecal-Oral route -food and water—vehicles -flies—vector Diagnostics Blood culture- positive for organism after 1st week Urine culture-positive for first two weeks Stool culture- positive after first week and through out the course of illness CLINICAL MANIFESTATION Gradual onset/Initial Stage Low grade to high fever Chills Diarrhea Abdominal pain with distention, hepatomegaly, splenomegaly Skin eruption; rose spots on abdomen, chest, trunk, back; each spots fades over a period of 3-4 days Second week High fever with rapid pulse Mental stupor, disorientation or delirium may appear due to toxemia Marked abdominal distention, tenderness, diarrhea or constipation Teeth and lips accumulate dirty brown collection of dried mucus and bacteria (SORDES) Decline of fever and subsidence of symptoms unless complications may occur Third week MANAGEMENT Maintain or restore F&E balance Position patient to avoid aspiration Monitor I&O, watch for bladder distention Encourage high fluid intake Perform TSB, administer antipyretics (Acetaminophen) Give high calorie, low residue diet during febrile stage Give non-gas forming foods, non-irritating foods Watch out for complications: perforation of the intestine; intestinal hemorrhage Administer Chlorampenicol: drug of choice; monitor blood count to monitor toxicity Administer combination of Sulfamethoxazole and Trimethroprim for Chlorampenicol-resistant strains of typhoid B. CHOLERA (EL TOR) Is a severe gastrointestinal disease characterized by vomiting and massive watery diarrhea with rapid dehydration and shock. Causative Agent: Vibrio El Tor (gram-negative) Mode of Transmission: Fecal-Oral route Indirect route (flies, soiled hands, utensils) Incubation Period: few hours to five days Period of Communicability: 7-14 days, occasionally 2-3 months Diagnostics: Stool Culture CLINICAL MANIFESTATIONS massive or profuse diarrhea (―rice water‖ and fishy odor stool) signs of severe dehydration; sunken fontanels and eyeballs, prominence of sutures, loss of turgor and elasticity of the skin, positive skin folds with wrinkling of the finger tips, cold clammy sweats and decreased BP loss of voice or aphonia vomiting, muscle cramps, and increased exhaustion oliguria and even anuria fever tetany, abdominal distention, convulsions Extracellular fluid volume loss acidosis- kussmaul’s respiration Hypokalemia profound or severe dehydration with washer woman’s hand, restlessness and extreme thirst circulatory collapse or shock TREATMENT rapid initial administration of lactated Ringer’s solution IV to expand the plasma volume initiate Oral Rehydration therapy early ORAL REHYDRATION SALTS (ORS) consists of 4 constituents Sodium Chloride Trisodium citrate or Sodium hydrogen carbonate (Sodium Bicarbonate) Potassium Chloride Glucose 3.5 grams 2.9 grams 2.5 grams 2.5 grams 20 grams to be dissolved in 1 liter of clean drinking water oral fluids are given in large amounts as tolerated tetracycline (not given to children under age 8) and cotrimaxazole- may shorten the period of diarrhea and hospitalization. Management isolation of patient: enteric precautions accurate recording of V/S, I&O disinfection of stool or proper disposal of the excreta boil water used for drinking C. POLIOMYELITIS (INFANTILE PARALYSIS) Is an acute infectious disease caused by any of the 3 types of poliomyelitis virus which affects chiefly the anterior horn cells of the spinal cord and the medulla, cerebellum, and the midbrain. This infection can lead to temporary paralysis or, in more severe cases, permanent paralysis or death. Causative Agent: Legio Debilitans 3 strains 1. Brunhilde 2. Lansing 3. Leon Mode of transmission: fecal-oral route Incubation Period: 7-14 days Period of Communicability: until 3 months as long as virus are still excreted in the feces CLINICAL MANIFESTATIONS SUBCLINICAL INFECTION No symptoms, or symptoms lasting 72 hours or less Slight fever Headache General discomfort or uneasiness (malaise) Sore throat Red throat Vomiting NONPARALYTIC POLIOMYELITIS Symptoms last 1 to 2 weeks Moderate fever Headache Vomiting Diarrhea Excessive tiredness, fatigue Irritability Pain or stiffness of the back, arms, legs, abdomen Muscle tenderness and spasm in any area of the body Neck pain and stiffness Pain front part of neck Back pain or backache Leg pain (calf muscles) Skin rash or lesion with pain Muscle stiffness PARALYTIC POLIOMYELITIS Fever, occurring 5 to 7 days before other symptoms Headache Stiff neck and back Muscle weakness, asymmetrical (only on one side or worse on one side) Abnormal sensations (but not loss of sensation) of an area Sensitivity to touch, mild touch may be painful Difficulty beginning to urinate Constipation Bloated feeling of abdomen Swallowing difficulty Muscle pain Muscle contractions or muscle spasms, particularly in the calf, neck, or back Drooling Breathing difficulty Irritability or poor temper control Positive Babinski's reflex DIAGNOSTICS Isolation of the Virus Serologic studies CSF exam Vaccination Salk Vaccine- solution of killed viruses that is given intramuscularly Sabin Vaccine- a preparation of attenuated living viruses that is administered orally Immunity confers long lasting Booster dose is recommended after a year in low SES MANAGEMENT Enteric precautions Provide resp. ventilation Apply moist hot packs to affected muscles for 15-30 minutes every 2-4 hours Maintain good body alignment by using boards, sandbags, etc Change position frequently Make bed with cotton or woolen blanket D.HEPATITIS IS A DIFFUSE INFLAMMATION OF THE LIVER PARENCHYMA CAUSED BY A VIRUS. Type/ Agent Source Mode of Incubation Period Of transmission communicability Fecal-oral route Sexual contact (oral-anal) 15-60 days / mean- 30 days A week before onset of S/SX and a week later HAV Feces & blood Picorna- urine virus HBV hepadn avirus Blood, bodily fluids including amniotic Parenteral Direct contact 50-180 days / Mean- 90 days Variable 2-5 mos / Mean- 50 days During acute phase; virus may persist in blood for years unknown Non A or Same as HBV Non B flavivirid ae Same as HBV NATURE OF DISEASE Type HAV onset Acute preicteric Highly contagious Fever (5 days) Anorexia, malaise, N/V, fatigue, headache, lassitude, RUQ pain Liver: enlarged and tender Flu-like URTI Similar to type A Often asso. with urticaria, arthralgia or arthritis With or without Jaundice Similar to HBV, less severe and anicteric icteric Jaundice with Scleral icterus Tenesmus, vague epigastric pain, N/V, indigestion, flatulence and abdominal tenderness Darked urine Clay colored stool Similar to HAV, jaundice is not as prominent Abdominal pain and general malaise may be noted Similar with HBV HBV Insidious Non A/B V May be sudden or gradual TREATMENT High CHO, moderate fat, low CHON diet Vitamin supplementation esp Vit B complex Virazole R (ribavirin) Isoprinosine (methisoprinol) Hyperimmune serum/Hyper immune Globulin Prevention of Hepatic coma Elimination of CHON Sterilization of GUT (Neomycin) Corticosteroids (prednisone) MANAGEMENT Enteric precaution/ avoid exposure to pt’s blood and other body fluids Promote rest during acute or symptomatic phase Improve nutritional status observe for melena and check stools for blood Plan periods of rest and activity Monitor/relief pruritus – cool moist compress, emolient lotion Administer corticosteroid as ordered PART III COMMUNICABLE DISEASES ACQUIRED THROUGH THE SKIN A. TETANUS (LOCK JAW, TRISMUS) acute disease induced by toxin of tetanus bacillus growing anaerobically in wounds and at site of umbilicus among infants (Tetanus Neonatorum) characterized by muscular contractions. Causative Agent: Clostridium Tetani Mode of Transmission: direct inoculation of the organism Incubation Period: 5-10 days Period of Communicability: not directly transmitted from man-to-man Pathogenesis Neurotoxin (Tetanospasmin)- responsible for the clinical manifestations or responsible for the muscular spasms Hemolysin (Tetanolysin)- responsible for the destruction of RBC and WBC CLINICAL MANIFESTATIONS Neonate Older children & Adults Onset between 3-10 days old, often present with difficulty in feeding and excessive crying Fever Stiffed jaw Variable tonic or rigid states of muscle contractions Opisthotonus, may or may not be present; deep tendon reflexes may be exaggerated Cyanosis or pallor May end with flaccidity, anorexia, exhaustion, and finally death Trismus or lockjaw Opisthotonus Risus sardinocus – pathognomonic sign Severe muscular spasm Headache and profuse sweating Immunizations Treatment Tetanus Immunoglobulin IM ATS IM Penicillin Tetracycline, if hypersensitive to Penicillin Diazepam Muscle Relaxant Active immunizations Tetanus toxoid- no need for skin testing DPT Passive immunization ATS- requires skin testing Human Tetanus Immune Globulin MANAGEMENT Maintain an adequate airway Provide cardiac monitoring Administer medications and immunization agents Support patient during titanic spasm and convulsions Place the patient in a quiet, semi-darked environment Avoid sudden stimuli and light Maintain F&E balance Avoid contractures and pressure sores Watch for urinary retention B. RABIES (HYDROPHOBIA, LYSSA) Is an acute viral encephalomyelitis caused by the rabies virus. Two kinds: urban or canine rabies are transmitted by dogs; sylvatic rabies is a disease of wild animals and bats The Philippines has one of the highest prevalence rates of rabies in the whole world Causative Agent: Rhabdovirus of the genus Lyssavirus Mode of Transmission: bite of a rabid animal; inoculation through a scratch or in a fresh break in the skin Incubation Period: 3-8 weeks (rabid animal); 10 days to 10 years (man) Period of Communicability: 3-10 days before the onset of clinical signs and through out the duration of the disease CLINICAL MANIFESTATIONS Prodromal/Invasion Phase State of excitement Sense of apprehension, irritability, restlessness Drowsiness, mental depression, melancholia, marked insomnia Fever, malaise, anorexia, Headache, sore throat Copious salivation, perspiration, lacrimation Sensitive to light, sound, and changes in temparature Sensory change near the site of animal bite Marked excitation, apprehension and even terror Delirium and convulsions Maniacal behavior alternates with listlessness and depression Eyes are fixed and glossy; skin is cold and clammy Spasms of muscles or deglutition Fear of water, Aerophobia Drooling Death may occur due to cardiac and respiratory failure Terminal/Paralytic Phase Paralysis Diagnostics A positive history of bite or contact by an animal infected with rabies Identification of Negri bodies in sample brain tissue of the infected animal Direct immunoflourescent test MANAGEMENT The wound must be immediately and thoroughly washed with soap and water Antiseptics and povidone iodine or alcohol may be applied Antibiotics and anti-tetanus may be given Capture the dog that inflicted the bite and keep under veterinary surveillance If animal remains healthy for 14 days, it is assumed that it was not infective If the dog shows sign suggestive of rabies, kill the dog humanely, decapitate and head packed in ice and send immediately to laboratory If dog is not available; submit for immunization MANAGEMENT Isolate the patient through out the course of illness Place paddings of bedside or use of restraints Clean and dress wound with the use of gloves to prevent contamination IVF should be placed behind the bed and cover it with paper bag or cloth No sight of water and electric fans should be seen Administer morphine as ordered C. MALARIA (AGUE) A specific infectious disease produced by any one of four protozoan parasites, which is transmitted to man by the bite of the mosquito, and the characteristic of which are chills followed by fever. Causative Agents: Protozoa Plasmodia Plasmodium Falciparum (Malignant Tertian) Most common in the Philippines Most serious Pernicious malaria Plasmodium Vivax (Benign tertian) Most widely distributed Much less frequent Plasmodium malariae (Quartan) Plasmodium Ovale Primary Vector Female Anopheles Night-bitting Breeds in clean, flowing and shaded streams Incubation Period P. Falciparum- 10-12 days P. Vivax- 14-17 days P. Malariae- 12-14 days P. Ovale- 11-26 days Period of Communicability P. Malariae- >3years P. Vivax- 1-2 years P. Falciparum- <1 year Clinical manifestations 1. Cold stage a. b. Last for 10-15 minutes Presence of chills Last for 4-6 hours n/v Fever Nose bleeding Headache Generalized weakness Sweating Decreased vital sign except BP 2. Hot Stage a. b. c. d. e. 3. Diaphoretic Stage a. b. c. Malarial cachexia a result of increasing destruction of red corpuscles and anemia that is progressively severe. irregular and intermittent fever hardened enlargement of spleen and liver. nose bleeding and purpura. severe anemia ashy yellow color Diagnostic Malarial Smear QBC – Quarantine Buffy Coat MANAGEMENT Anti-Malarial Chloroquine (except for P. Malariae) Quinine Sulfadoxine (P> Falciparum) Primaquine (Relapse of P. Vivax and P. Ovale NATIONAL POLICY ON DIAGNOSIS AND MANAGEMENT OF MALARIA, 2002 Combination Treatment – P. falciparum Chloroquine and Sulfadoxine-Pyrimethamine (CQ+SP) 1st line drugs for probable and confirmed cases Artemether-Lumefantrine (Coartem) (A-L) 2nd line drug used only in confirmed cases which fail CQ+SP; not recommended in pregnancy, lactation, infants < 1 yr, severe malaria COMBINATION TREATMENT – P. FALCIPARUM Quinine in combination with either Tetracycline or Doxycycline (Q + T/D) 3rd line drug - uncomplicated P. falciparum w/c fail A-L; 2nd line drug if A-L is unavailable; Drug of choice for severe/complicated P. falciparum malaria; combine with Clindamycin if T and D are contraindicated ( e.g. pregnant women, children < 8 y/o) Primaquine given on the 4th day as a single dose to all microscopicallyconfirmed P. falciparum contraindicated in pregnant women and children < 1 y/o COMBINATION TREATMENT – P. VIVAX Chloroquine For confirmed P. vivax cases AND Primaquine Given for 14 days to prevent relapse not given to pregnant women and infants < 1 y/o PREGNANT WOMEN AND CHILDREN < 1 Y/O: Quinine Drug of choice in treatment of malaria in pregnancy, regardless of the period of pregnancy Used for children < 1 y/o who fail CQ+SP Chloroquine and Sulfadoxine-Pyrimethamine (CQ+SP) In treatment of probable malaria In case Quinine is unavailable for confirmed P. falciparum given after the first trimester of pregnancy CHEMOPROPHYLAXIS Doxycycline 100 mg tablet daily, starting 2 – 3 days prior to travel to continue up to 4 wks upon leaving the area Contraindicated in pregnant and lactating women & children < 8 y/o OR Mefloquine 250 mg base (tablet) weekly starting one week before travel to continue up to 4 wks upon leaving the area CHEMOPROPHYLAXIS - PREGNANT WOMEN Particularly primigravid during the entire pregnancy and stay in endemic areas. Chloroquine Generally safe and has little teratogenic risk Given on the first trimester of pregnancy Two tablets weekly, two wks before travel, during stay and until 4 wks after leaving the area. Sulfadoxine-Pyrimethamine on the second and third trimester of pregnancy MANAGEMENT Tepid to cool sponges Provide adequate fluids Monitor V/S esp. Temp. Provide diet high in vitamins, calories, minerals. Maintain fluid and electrolyte balance Oral hygiene should be maintained Iron rich foods for anemia D. DENGUE AND DENGUE HEMORRHAGIC FEVER Breakbone Fever, Dandy Fever Acute febrile disease caused by infection with one of the serotypes of dengue virus which is transmitted by Genus Aedes DHF- severe, fatal manifestation characterized by bleeding and shock Causative Agents: Flaviviruses 1,2,3,4 (Togaviridae) Arbovirus type B (Chikungunya) Onyong-yong virus Mode of Transmission: Bite of infective Aedes Aegypti (day-bitting) Incubation Period: 4-7 days Period of Communicability Man: 1 day before febrile period until the end of it Mosquito: 8-12 days after blood meal Diagnostics Tourniquet test (Rumpel Lead Test) Platelet count- decreased (confirmatory) CLINICAL MANIFESTATIONS Initial Febrile Phase (2-3 days) Fever accompanied by headache, convulsions Palms and soles flushed Positive Tourniquet Test Anorexia, vomiting, myalgia Herman’s signpathognomonic sign Epistaxis, gum bleeding Circulatory phase (4-7 days) Restless, cool clammy skin Decreased temperature Cyanosis Thrombocytopeniashock Bleeding CLASSIFICATION Grade 1 Fever, positive tourniquet test Positive spontaneous bleeding from nose, gum, and GIT With circulatory failure, weak pulse, narrow pulse pressure, hypotension, cold and clammy skin, restless Profound shock, undetectable BP and pulse Grade 2 Grade 3 Grade 4 Weil’s E. LEPTOSPIROSIS disease, Canicola Fever, Mud Fever, Swineherd’s disease, Japanese 7 days fever, Trench fever, Flood fever, Spiroketal fever Infection carried by animals, both domesticated and wild, whose excreta contaminate water or food which ingested or inoculated through the skin or mucous membrane Causative Agent: Leptospira Interrogans, L. Pyrogenes, L. Manilae Mode of Transmission: direct contact on the skin or mucous membrane especially open wounds Incubation Period: 5-6 days CLINICAL MANIFESTATIONS Septicemic stage Febrile lasting 4-7 days Chills, headache, anorexia, N/Vabdominal pain Joint pains, muscle pains, myalgia Immune or Toxic stage (With or without jaundice lasting for 30 days) Anicteric- low grade fever with rash, conjuntival injection, headache, disorientation, convulsion Icteric- (Weil’s syndrome)- jaundice, hepatic and renal manifestations Shock, coma, and CHF in severe cases Convalescence Diagnostics Spirochetes Culture Treatment Penicillin (Drug of Choice) Tetracycline Administration of F&E, blood as needed Peritoneal Dialysis F. LEPROSY (HANSEN’S DISEASE) A chronic disease with insidious onset characterized by progressive cutaneous lesions Causative Agent: Mycobacterium Leprae not highly contagious and has low infectivity Mode of Transmission: prolonged skin-to-skin contact; droplet infection Incubation Period: 5 ½ months – 8 years Period of Communicability: as long as there are open lesions Diagnostic: Tissue Biopsy/Smear CLINICAL MANIFESTATIONS Early Signs/Sx Change in skin color Loss of sensation on the skin lesion Decrease/Loss sweating and hair growth over the lesion Thickened and/or painful nerves Muscle weakness or paralysis of extremities Pain and redness of the eye Nasal obstruction or bleeding Ulcers that do not heal Later S/SX Loss of eyebrow-madarosis Inability to close eyelidslagophthalmos Clawing of fingers and toes Contractures Sinking of the nose bridge Gynecomastia Leonine face TREATMENT Multi-Drug Therapy Rifampicin Dapsone Clofazimine CLASSIFICATION: BASED ON THE CLINICAL SIGNS AND SYMPTOMS; SERVES AS A GUIDE FOR PRESCRIBING THE APPROPRIATE Characteristic MDT REGIMEN. Single Lesion Paucibacillary (SLPB) Only one lesion Paucibacillary (PB) 2 – 5 lesions Asymmetrically distributed Definite loss of sensation None or one nerve trunk Multibacillary (MB) More than 5 lesions Symmetrically distributed Loss of sensation Many nerve trunks Skin Lesions (includes: macules– flat lesions papules – raised lesions and nodules) Nerve Damage (resulting in loss of sensation or weakness of muscles supplied by the affected nerve) No nerve trunk involvement TREATMENT MDT is safe, effective and easily administered under field conditions. PB patients treated with MDT are cured within six months; MB patients treated with MDT are cured within 12 months; Patients are no longer infectious to others after the first dose of MDT, thus transmission of leprosy is interrupted; There are virtually no relapses of the disease after treatment is completed; No resistance of the bacillus to MDT has been detected. MULTIDRUG THERAPY REGIMEN Adult MB Regimen Monthly Treatment: Day 1 Rifampicin 600 mg Clofazimine 300 mg Dapsone 100 mg Daily Treatment: Days 2-28 Clofazimine 50 mg Dapsone 100 mg Child MB Regimen Monthly Treatment: Day 1 Rifampicin 450 mg Clofazimine 150 mg Dapsone 50 mg Daily Treatment: Days 2-28 Clofazimine 50 mg every other day Dapsone 50 mg daily Duration of Treatment: Duration of Treatment: 12 blister packs to be taken monthly within a 12 blister packs to be taken monthly within a maximum period of 18 months. maximum period of 18 months. For children below 10 years old, the dose may be adjusted. (e.g.: rifampicin 300 mg, dapsone 25 mg, and clofazimine 100 mg once a month and 50 mg twice a week) MULTIDRUG THERAPY REGIMEN Adult PB Regimen Monthly Treatment: Day 1 Rifampicin 600 mg Dapsone 100 mg Daily Treatment: Days 2-28 Dapsone 100 mg Duration of Treatment: 6 blister packs to be taken monthly within a maximum period of 9 months. Child PB Regimen Monthly Treatment: Day 1 Rifampicin 450 mg Dapsone 50 mg Daily Treatment: Days 2-28 Dapsone 50 mg daily Duration of Treatment: 6 blister packs to be taken monthly within a maximum period of 9 months. For children below 10 years old, the dose may be adjusted. (e.g.: rifampicin 300 mg, dapsone 25 mg) MULTIDRUG THERAPY REGIMEN ROM Regimen for SLPB: Adult Rifampicin 600 mg (2 x 300 mg) Ofloxacin 400 mg (2 x 200 mg) Minocycline 100 mg (2 x 50 mg) Duration of Treatment: 2 packs ROM Regimen for SLPB: Child (5 – 14 y/o) Rifampicin 300 mg (1 x 300 mg) Ofloxacin 200 mg (1 x 200 mg) Minocycline 50 mg (1 x 50 mg) Duration of Treatment: 1 pack Completion of Treatment and Cure: Any PB patient who has taken six doses of PB-MDT within 9 months should be considered as cured. Any MB patient who has taken 12 doses of MB-MDT within 18 months should be considered as cured. MDT SIDE EFFECTS Gastric irritation due to clofazimine brownish discoloration of the skin and ichthyosis due to clofazimine – disappears a few months after stopping treatment Allergy - skin rashes, exfoliative dermatitis due to dapsone Body malaise, joint and muscle pains due to rifampicin Psychosis due to dapsone (rare cases) IMPORTANT! Any patient with a positive skin smear, irrespective of clinical classification, should be treated with MDT regimen for MB Leprosy. When classification is in doubt, treat patient with MDT regimen for MB Leprosy. This ensures that patients with MB disease is not treated with regimen for PB disease. MANAGEMENT Full, wholesome, generous diet TSB may be used for high fever Patient should have a daily cleansing bath and change of clothing Good oral hygiene Normal elimination should be maintained Meticulous skin care for ulcers G. ANTHRAX Causative Agent: Bacillus Anthracis Mode of Transmission Direct—contact with animals/ animal products Indirect—animal bites, ingestion of animal meats Airborne Incubation Period: Few hours to 7 days CLINICAL MANIFESTATIONS Cutaneous Itch Papules Vesicles (4th day) Ulceration—Eschar (5-7 days) edema Inhalation (Woolsorter’s disease) Respiratory manifestations-- death GIT Violent gastroenteritis Vomiting and bloody stools H. FILARIASIS (ELEPHANTIASIS) Causative Agent: Wuchereria bancrofti, Brugia malayi, and Brugia timori, Vectors Aedes (poecilius)- 10-12pm, abaca, banana Anopheles (flavirostris)- 10pm-2am, flowing streams Culex (quinquefasciatus)- bites by night, polluted water Mansonia (uniformis) – night, swampy areas Incubation Period: 8-16 months Diagnostic Exam: Giemsa stained Nocturnal Blood Exam (NBE) Clinical Manifestations Fever inguinal or axillary lymphadenopathy testicular and/or inguinal pain skin exfoliation limb or genital swelling Management Albendazole (broad spectrum anti-helminthic) 400 mg PO single dose Ivermectin (Mectizan) 150-200 mcg/kg/d PO as single dose; repeat q2-3mo Diethylcarbamazine Citrate (Hetrazan) 6 mg/kg PO qd for 12 d to 3 wk Flubendazole (Fluvermal) 100 mg PO bid for 3 days MANAGEMENT Bed rest Limb elevation Compression bandages Administer antihistamines, steroids, pain relief, and intravenous antibiotics for secondary infections Administer steroids can be used to soften and reduce the swelling of lymphedematous tissues I. SCHISTOSOMIASIS ( BILHARIASIS, BILHARZIOSIS OR SNAIL FEVER) Causative Agent: Schistosoma haematobium, Schistosoma mansoni, or Schistosoma japonicum (blood fluke) Vector: Oncomelania Quadrasi Diagnosis : Direct Fecal Smears MANIFESTATIONS Fever Headache Malaise Arthralgias/myalgias Cough Bloody diarrhea Right upper quadrant (RUQ) pain Rash - Urticarial and/or papular Eosinophilia- extremely high Praziquantel- DOC S haematobium and S mansoni: 40 mg/kg/d PO divided bid for 1 d S japonicum: 60 mg/kg/d PO divided tid for 1 d Trivalent Antimony MANAGEMENT Tartar Emetic- IV Stibophen- IM Niridazole- 25mg/kg/day po OD x 10 days PART IV COMMUNICABLE DISEASES ACQUIRED THROUGH GENITO-URINARY TRACT A. GONORRHEA GC, Clap, Drip (Tulo), Gleet, Flores Blancas, Gonoclap, Jack Is an infection involving the mucosal surface of the Genitourinary Tract, rectum, and the Pharynx and even eyes. Causative Agent: Neisseria Gonorrheae (Gram (-) coccus Mode of Transmission: Sexual contact Direct contact with newborn Incubation Period: 2-5 days, sometimes longer Period of Communicability: As long as the Gonococci are present in patient CLINICAL MANIFESTATIONS Male Burning sensation in the Urethra upon urination Dysuria with purulent discharges Pelvic pain, fever Prostatitis Female Burning sensation upon urination Presence or absence of vaginal discharges Frequent urination Redness, swelling Urethritis, Endometritis, cervicitis Abdominal distention, N/V Diagnostics Gram staining Culture and sensitivity Pap smear Treatment Penicillin (Drug of Choice) Ceftriaxone Doxycycline Erythromycin (for pregnant mothers) Management Educate men and women to recognize signs and symptoms and to seek immediate treatment Monitor urinary and bowel elimination Isolate until the patient recovers from illness B. SYPHILIS (LEUS VENEREA, MORBUS GALLICUS, THE POX, BAD BLOOD) A contagious disease that leads to many structural and cutaneous lesions Causative Agent: Treponema Pallidum (Spirochete) Mode of transmission: Sexual contact Indirect contact Congenital Incubation Period: 10-90 days, average of 21 days Period of communicability: up until 5 years after the onset of infection Diagnostics Flourescent treponemal antibody absorption Test (FTA-ABS) CLINICAL MANIFESTATIONS Primary Chancres on genitalia, mouth or anus(painless) Enlarged lymph nodes Starts as papules then erodes (disappears in 3-6 weeks) Secondary (1 week-6 months after appearance of chancres) Rash (macular-papular-pustular-nodular), uniform in size Alopecia Nails- brittle and pitted Generalized lymphadenopathies Iritis Arthritic and bone pain Tertiary (may occur 10-30 years) Gummas Cardiovascular changes, bone, liver, CNS < > T Penicillin REATMENT Topical corticosteroids management: 1. 2. 3. Strict personal hygiene Instruct client to avoid sexual contact until clearance is given. Explain need to complete course of antibiotic therapy D. CHANCROID a fastidious Gram-negative streptobacillus causing the sexually transmitted disease chancroid characterized by painful sores on the genitalia. Causative Agent: Haemophilus ducreyi Incubation Period: 3-5 days, 14 days(longer) Period of Communicability: as long as the infected person has open sore(s) CLINICAL MANIFESTATIONS WOMEN - Painful, ulcerated, open sores on the genitals; may have swollen lymph nodes in the groin; painful urination and defecation; vaginal discharge; rectal bleeding MEN - Painful, ulcerated, open sores or ulcerations on the genitals and may have swollen lymph nodes in the groin Drug Therapy Ceftriaxone (Rocephin) Azithromycin (Zithromax) Erythromycin (E.E.S., E-Mycin, Ery-Tab) Ciprofloxacin (Cipro) D. ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) Is a complex disease characterized by a collapse of the body’s natural immunity against disease It is currently a Pandemic problem As of May 2000, there were 1,385 HIV positive, 464 AIDS cases (PNAC) Causative Agent: Retrovirus- Human T-cell lymphotropic virus 3 (HTLV-3) Incubation Period: variable; 3-6 months or longer 8-10 years ADULTS AND CHILDREN ESTIMATED TO BE LIVING WITH HIV AS OF END 2005 Western & Central Eastern Europe & Central Asia Europe North America [650 000 – 1.8 million] 1.2 million [570 000 – 890 000] [990 000 – 2.3 million] East Asia 720 000 1.6 million Caribbean [200 000 – 510 000] North Africa & Middle East [230 000 – 1.4 million] 300 000 510 000 [440 000 – 1.4 million] 870 000 South & South-East Asia Latin America [1.4 – 2.4 million] Sub-Saharan Africa [23.8 – 28.9 million] 7.4 million 1.8 million 25.8 million [4.5 – 11.0 million] [45 000 – 120 000] 74 000 Oceania Total: 40.3 (36.7 – 45.3) million GLOBAL SUMMARY OF THE HIV AND AIDS EPIDEMIC, DECEMBER 2005 Number of people living with HIV in 2005 Adults Women Children under 15 years People newly infected with HIV in 2005 Adults Children under 15 years 40.3 million (36.7 – 45.3 million) 38.0 million (34.5 – 42.6 million) 17.5 million (16.2 – 19.3 million) 2.3 million (2.1 – 2.8 million) 4.9 million (4.3 – 6.6 million) 4.2 million (3.6 – 5.8 million) 700 000 (630 000 – 820 000) AIDS deaths in 2005 Adults Children under 15 years 3.1 million (2.8 – 3.6 million) 2.6 million (2.3 – 2.9 million) 570 000 (510 000 – 670 000) The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information. people diagnosed & registered People NOT diagnosed & / or NOT registered Or WHO DO NOT COME OUT Mode of Transmission Sexual contact Blood transfusion Contaminated syringes, needles, nipper, razor blades Direct contact of open wounds/mucous membrane with contaminated blood, body fluids, semen, vaginal discharges Perinatal CLINICAL MANIFESTATIONS Physical: maculo-papular rashes Loss of appetite Weight loss (10%)* Fever of unknown origin (a month)* Malaise Persistent diarrhea (a month)* Tuberculosis (localized or disseminated) Herpes zoster, herpes simplex Esophageal candidiasis Generalized lymphadenopathy Kaposi’s sarcoma- for ccancer pt Pnuemocystis carinii pneumoniapneuumonia Guant-looking, apprehensive Early stage Loss of concentration Loss of libido Apathy Psychomotor retardation Withdrawal Confusion Disorientation-dementia Seizures Mutism Loss of memory Coma Late stage Mental Forgetfulness *n.b. major manifestations * Protozoal - Pneumocystis carinii Pneumonia (PCP) - Toxoplasmosis gondii - brain * Bacterial - Mycobacterium tuberculosis - Mycobacterium avium complex – lung, liver, bone marrow - Treponema pallidum - syphilis, neurosyphilis ppresence of Gummas * Fungal - Candida - mouth, esophagus, vagina, trachea bronchi, lungs - Cryptococcus neoformans - Meningitis * Viral - Herpes simplex – Recurrent perioral, perirectal, or genital ulcers; esophagitis, retinal necrosis - Cytomegalovirus – retinitis, esophagitis, colitis, pneumonia - Varicella-zoster – cutaneous, retinal necrosis * * Kaposi’s Sarcoma - vascular nodules in skin, mucous membranes, viscera * Lymphoma – benign: Hodgkin’s and nonhodgkin(benign cancer of the lymphnodes) •Cervical cancer, invasive •ELISA- test-screening test for HIV not a confirmatory test{look for the production of antibodies; twice positive(with contact)} •Western Blot test-confirm Prevention ABSTINENCE Avoid behaviors that put you at risk of infection, e.g. sharing needles and having unprotected sex. BE FAITHFUL Stick to only one partner CAREFUL SEX ( CONDOMS ) Protect self by using latex condoms during oral, anal or vaginal sex. Prevention DON’T USE PROHIBITED DRUGS EDUCATION Diagnostics Enzyme Linked Immuno Sorbent Assay (ELISA)- presumptive Test Western Blot- Confirmatory test Treatment: Symptomatic and Supportive Teget cell of the Virus- immune cells Drugs Reverse Transcriptase Inhibitors(convert RNA-DNA) Retrovir (zidovudine, azidothymidine, AZT, ZDV) Emtriva (emtricitabine, FTC) Epivir (lamivudine, 3TC) Epzicom (abacavir and lamivudine) Protease Inhibitors (inhibit the virus in engulfing proteins) Agenerase (amprenavir, APV) Aptivus (tipranavir, TPV) Crixivan (indinavir, IDV) Invirase (saquinavir mesylate, SQV) MANAGEMENT Provide frequent rest periods. Provide skin care Provide high calorie, high CHON diet Provide good oral hygiene(for oral thrush) Provide oxygen and maintain pulmonary function Provide measures to reduce pain(kaposis sarcoma) Protect the client from secondary infection Teach client the importance of: Informing sexual contacts of diagnosis Not sharing needles with other individuals Continuing medical supervision WORM INFESTATIONS ROUNDWORM (ASCARIASIS) Most common intestinal worm infection Causative Agent: Ascaris lumbricoides Confidentiality- holding the information Anonimity- holding in names, identity Beneficence Non beneficence Maleficence Ascariasis are sensitive to anesthetics CLINICAL MANIFESTATIONS Passing worms in stool Vomiting up worms Worms exiting through the nose or mouth Low-grade fever Cough Bloody sputum Wheezing Shortness of breath Skin rash Vomiting Stomach pain MANAGEMENT Drug Mebendazole (Vermox) – 100mg q 12 x 3 days Piperazine – 75 mg/kg once Pyrantel Pamoate (Combantrin) – 11mg/kg once Consideration use of toilet facilities safe excreta disposal protection of food from dirt and soil thorough washing of produce hand washing. PINWORM (ENTEROBIASIS) Agent: Enterobius Vermicularis Symptoms painful itching around the anus restless sleep poor appetite skin rash failure to gain weight MANAGEMENT Drug Therapy Pyrantel (Antiminth, Combantrin) Mebendazole (Vermox) Cut fingernails Handwashing Administer second dose after 2 weeks