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Unit ONE Introduction to COMMUNICABLE DISEASE CONTROL /CDC By Zinabu Dawit ( PBsc ) By zinabu D 1

Objective At the end of this chapter the student should be able to define Define Communicable Disease Explain common terms Describe chain of disease transmission By zinabu D 2

Introduction to communicable diseases control What are a communicable diseases ? Example: What are a non-communicable diseases? Example: By zinabu D 3

Communicable Diseases Is an illness due to specific infectious agent or its products arises through transmission of that agent or its products an infected person, animal or inanimate reservoir to a susceptible host . The transmission may occur either directly or indirectly through an intermediate host which can be plant or animal or a non living thing, or in both direct and indirect. By zinabu D 4

Cont Communicable Diseases control It refers to the reduction of the incidence & prevalence of diseases to level where it can not be a major public health problem. By zinabu D 5

DEFINITION OF COMMON TERMS Transmission :- is the process by which an infectious agent or its products passes from the source to the new host. Period of communicability :- the time during which the infectious agent may be transferred from infected person to another. Incubation period :- The time interval between initial contact with the infectious agent and the appearance of the first sign or symptoms of the disease. By zinabu D 6

Cont Prodormal period : The time interval between the onset of symptoms of an infectious disease and the appearance of characteristic manifestations . E.g. In measles from the onset of fever and coryza to the development of characteristic signs like koplick’s spots and characteristic skin lesions. By zinabu D 7

Cont Prepatent period : The period in people between the time of exposure to a parasite and the time when the parasite can be detected in blood or in stool. Incubation period in a vector: is the time between entrance of an organism in to the vector and the time when that vector can transmit the infection (extrinsic incubation period). By zinabu D 8

Cont Exposure : The contact between the agent and susceptible host. Infectivity : The ability of an agent to invade and multiple in a host. Pathogencity : The ability of an agent to produce clinically apparent disease , or the property of an infectious agent that determines the extent to which overt dx is produced. By zinabu D 9

Cont, Virulence : The ability of infectious agent to produce severe disease among clinically infected persons. Immunogenicity : The ability of an agent to produce specific immunity Illness : Individual or subjective feeling of discomfort. By zinabu D 10

Cont Infectious agent- an agent capable of causing infection Contamination – presence of living infectious agent upon Articles Infestation – presence of living infectious agent on the exterior surface of the body Infection - the entry and development or multiplication of an infectious agent in the body of man or animal By zinabu D 11

Cont Infectious: caused by microbes and can be transmitted to other persons Disease :a state of physiological or psychological dysfunction. Epidemics : the occurrence of any health related condition in a given population in excess of the usual frequency in that population. Endemic : a disease that is usually present in a population or in an area at a more or less stable level. By zinabu D 12

Cont Sporadic - a disease that does not occur in that population, except at occasional and irregular intervals. Pandemic - an epidemic disease which occurs worldwide By zinabu D 13

Chain of disease transmission This refers to a logical sequence of factors or links of a chain that are essential to the development of the infectious agent and propagation of disease. The six factors involved in the chain of disease transmission are: By zinabu D 14

Chain of diseases transmission By zinabu D 15

Cont Infectious agent (aetiology or causative agent) Reservoir Portal of exit Mode of transmission Portal of entry Susceptible host By zinabu D 16

Infectious Agent An organism that is capable of producing infection or infectious disease. On the basis of their size, etiological agents are generally classified into: Metazoa ( multicellular organisms). (e.g. Helminths ). Protozoa (Unicellular organisms) (e.g. Ameobae ) Bacteria (e.g. Treponema pallidum, Mycobacterium tuberculosis, etc.) Fungus (e.g. Candida albicans ) Virus (e.g. Chickenpox, polio, etc.) By zinabu D 17

Reservoir Any person, animal, arthropod, plant, soil or substance (or combination of these) in which an infectious agent normally lives and multiplies, on which it depends primarily for survival and where it reproduces itself in such a manner that it can be transmitted to a susceptible host. By zinabu D 18

Types of Reservoirs Man: There are a number of important pathogens that are specifically adapted to man, such as: measles, smallpox, typhoid, meningococcal meningitis, gonorrhea and syphilis. The cycle of transmission is from human to human. By zinabu D 19

Cont.. II. Animals: Some infective agents that affect man have their reservoir in animals. The term “ zoonosis ” is applied to disease transmission from animals to man under natural conditions. For example: Bovine tuberculosis - cow to man Brucellosis - Cows, pigs and goats to man Anthrax - Cattle, sheep, goats, horses to man Rabies - Dogs, foxes and other wild animals to man By zinabu D 20

Cont... 3.N on-living things as reservoir: Many of the agents are basically saprophytes living in soil and fully adapted to live freely in nature. Biologically, they are usually equipped to withstand marked environmental changes in temperature and humidity. E.g. Clostridium botulinum etiologic agent of Botulism Clostridium tetani etiologic agent of Tetanus Clostridium welchi etiologic agent of gas gangrene By zinabu D 21

3. Portal of exit This is the site through which the agent escapes from the reservoir. Examples include: GIT : typhoid fever, bacillary dysentery, amoebic dysentery, cholera, ascariasis , etc Respiratory : tuberculosis, common cold, etc. Skin and mucus membranes : Syphilis By zinabu D 22

4.Mode of transmission Refers to the mechanisms by which an infectious agent is transferred from one person to another or from a reservoir to a new host. Transmission may be direct or indirect. Direct transmission: Consists of essentially immediate transfer of infectious agents from an infected host or reservoir to an appropriate portal of entry. By zinabu D 23

Cont This could be: I. Direct Vertical Such as: transplacental transmission of syphilis, HIV, etc. II. Direct horizontal Direct touching, biting, kissing, sexual intercourse, droplet spread onto the conjunctiva or onto mucus membrane of eye, nose or mouth during sneezing coughing, spitting or talking; Usually limited to a distance of about one meter or less. By zinabu D 24

Cont II. Indirect transmission A.Vehicle -borne transmission: Indirect contact through contaminated : Inanimate objects ( fomites ) like: Bedding, toys, handkerchiefs, soiled clothes, cooking or eating utensils, surgical instruments. Contaminated food and water. Biological products like blood, serum, plasma or IV-fluids or any substance serving as intermediate means by which an infectious agent is transported and introduced into a susceptible host through a suitable portal of entry. By zinabu D 25

Cont.. B. Vector-borne transmission : Occurs when the infectious agent is conveyed by an arthropod (insect) to a susceptible host. Mechanical transmission : The arthropod transports the agent by soiling its feet or proboscis, in which case multiplication of the agent in the vector does not occur. ( e.g.common house fly.) By zinabu D 26

Cont... 2. Biological transmission: This is when the agent multiplies in the arthropod before it is transmitted, such as the transmission of malaria by mosquito. C. Air-borne transmission: Dissemination of microbial agent by air to a suitable portal of entry, usually the respiratory tract. Two types of particles are implicated in this kind of spread: dusts and droplet nuclei. By zinabu D 27

Cont... Dust: Small infectious particles of widely varying size that may arise from soil, clothes, bedding or contaminated floors and be re-suspended by air currents . Droplet nuclei : Small residues resulting from evaporation of fluid (droplets emitted by an infected host). They usually remain suspended in the air for long periods of time. By zinabu D 28

5. Portal of entry The site in which the infectious agent enters to the susceptible host. For example: Mucus membrane Skin Respiratory tract GIT Blood By zinabu D 29

6.Susceptible host A person or animal lacking sufficient resistance to a particular pathogenic agent to prevent disease if or when exposed. occurrence of infection and its outcome are in part determined by host factors. The term “immunity” is used to describe the ability of the host to resist infection. Resistance to infection is determined by non-specific and specific factors: By zinabu D 30

Cont.. Non-specific factors Skin and mucus membrane Mucus, tears, gastric secretion Reflex responses such as coughing and sneezing. Specific factors Genetic- hemoglobin resistant to Plasmodium falciparum Naturally acquired or artificially induced immunity. Acquired immunity may be active or passive By zinabu D 31

Cont.. Active immunity: Acquired following actual infection or immunization. Passive immunity : pre-formed antibodies given to the host. By zinabu D 32

Carrier and Its Type A carrier is an infected person or animal who does not have apparent clinical disease but is a potential source of infection to others. Healthy or asymptomatic carriers: These are persons whose infection remains unapparent. For example, in poliovirus, meningococcus and hepatitis virus infections, there is a high carrier rate. By zinabu D 33

Cont... B. Incubatory or precocious carriers: These are individuals or persons who excrete the pathogen during the incubation period (i.e. before the onset of symptoms or before the characteristic features of the disease are manifested). E.g. Measles, mumps, chickenpox and hepatitis . By zinabu D 34

Cont.. C. Convalescent Carriers: These are those who continue to harbor the infective agent after recovering from the illness. E.g. Diphtheria, Hepatitis B virus . D. Chronic Carriers: The carrier state persists for a long period of time. E.g. Typhoid fever, Hepatitis B virus infection By zinabu D 35

Time Course of Infectious Diseases Incubation period : It is the interval of time between infection of the host and the first appearance of symptoms and signs of the disease. Prodormal period : It is the interval between the onset of symptoms of an infectious disease and the appearance of characteristic manifestations. By zinabu D 36

For example, in a measles Patient, fever and coryza occur in the first three days and Koplick spots in the buccal mucosa and characteristics skin lesions appear on the fourth day. By zinabu D 37

Cont.. Period of communicability: The period during which that particular communicable disease (infectious agent) is transmitted from the infected person to the susceptible host. By zinabu D 38

Levels of Prevention Three levels of prevention: primary, secondary, and tertiary. A.Primary prevention: The objectives here are to promote health, prevent exposure, and prevent disease . Health promotion . E.g . affordable and adequate housing, old-age pension benefits; emotional and social support, education and vocational training etc Prevention of exposure E.g . provision of safe and adequate water, vector control, proper excreta disposal, etc. Prevention of disease . This occurs during the latency period between exposure and the biological onset of disease. E.g. Immunization By zinabu D 39

Cont... B. Secondary prevention: After the biological onset of disease, but before permanent damage. The objective here is to stop or slow the progression of disease so as to prevent or limit permanent damage, through the early detection and treatment of disease . E.g. Breast cancer (prevention of the invasive stage of the disease), Trachoma (prevention of blindness) syphilis (prevention of tertiary or congenital syphilis) By zinabu D 40

Cont... C. Tertiary prevention : After permanent damage has set in, The objective of tertiary prevention is to limit the impact of that damage. The impact can be physical, psychological, social (social stigma or avoidance by others), and financial. Rehabilitation refers to the retraining of remaining functions for maximum effectiveness . By zinabu D 41

Communicable Disease Control This refers to the reduction of the incidence and prevalence of communicable disease to a level where it cannot be a major public health problem. Methods of Communicable Disease Control Elimination of the Reservoir Interruption of transmission Protection of susceptible host By zinabu D 42

I.Elimination of the reservoir Man as reservoir : When man is the reservoir, eradication of an infected host is not a viable option. Instead, the following options are considered. Detection and adequate treatment of cases Isolation - separation of infected persons for a period of communicability of the disease. Quarantine- limitation of the movement of apparently well person who has been exposed to infectious diseases. By zinabu D 43

Cont.. B. Animals as reservoir Action will be determined by the usefulness of the animals, how intimately they are associated to man and the feasibility of protecting susceptible animals. E.g : Rabies: Pet dogs can be protected by vaccination but stray dogs are destroyed. Infected animals used for food are examined and destroyed. By zinabu D 44

Cont.. C. Reservoir in non-living things: Possible to limit man’s exposure to the affected area (e.g. Soil, water, forest, etc.). By zinabu D 45

II.Interruption of transmission This involves the control of the modes of transmission from the reservoir to the potential new host through: Improvement of environmental sanitation and personal hygiene Control of vectors Disinfections and sterilization By zinabu D 46

III.Protection of susceptible host This can be achieved through: Immunization: Active or Passive Chemo-prophylaxis- (e.g . Malaria, meningococcal meningitis, etc.) Better nutrition Personal protection. (e.g. wearing of shoes, use of mosquito bed net, insect repellents, etc.) By zinabu D 47

By zinabu D 48 Thank You!!

UNIT TWO FECO-ORAL TRANSMITED DISEASES By Zinabu Dawit By zinabu D 49

INTRODUCTION Causative agents are excreted in the stools of infected persons. The portal of entry for these diseases is the mouth. By zinabu D 50

Cont, Thus the causative organisms have to pass through the environment from the feces of an infected person to the gastro-intestinal tract of a susceptible person This is known as the fece -oral transmission route This transmission occurs mostly through unapparent fecal contamination of food, water and hands Food takes a central position; it can be directly or indirectly contaminated via polluted water, dirty hands, contaminated soil, or flies. By zinabu D 51

By zinabu D 52

Five “ fs ” fecal oral diseases transmission By zinabu D 53 Flies Finger Fomites Fluid Food Mouth Feces

. MANAGE A PATIENT WITH FECO-ORAL TRANSMITED DISEASE By zinabu D 54

TYPHOID FEVER A systemic infectious disease characterized by high continuous fever, malaise & involvement of Lymphoid tissues. Etiology: Salmonella typhi Salmonella enteritidis By zinabu D 55

Epidemiology Occurrence: It occurs worldwide, particularly in poor socioeconomic areas. Annual incidence is estimated at about 17 million cases with approximately 600,000 deaths worldwide. In endemic areas the disease is most common in preschool and school aged children (5-19 years ofage ). By zinabu D 56

Cont, Reservoir : Human as a case or as a carrier. Temporary carrier: that excretes the organisms for at least 6-8 weeks. Chronic carrier : which excretes the organisms for at l east 1 year. In some cases, it can be life long. By zinabu D 57

Mode of transmission By water and food contaminated by feces and urine of patients and carriers. Flies may infect foods in which the organisms then multiply to achieve an infective dose. By zinabu D 58

Cont, Incubation period –1-3 weeks Period of communicability: As long as the bacilli appear inexcreta , usually from the first week throughout convalescence. About 10% of untreated patients will discharge bacilli for 3 months after onset of symptoms,And 2%-5% become chronic carriers. By zinabu D 59

Susceptibility And Resistance Susceptibility is general and increased in individuals with gastric achlorhydria or those who are HIV positive. By zinabu D 60

Clinical manifestation First week: Mild illness characterized by: Fever rising stepwise(ladder type), Anorexia, lethargy, malaise and General aches. Dull and continuous frontal headache is prominent. Nose bleeding, vague abdominal pain and Constipation in 10% of patients. By zinabu D 61

Second week: Sustained temperature (fever). Severe illness with weakness, mental delirium, Abdominal discomfort and distension. Diarrhea is more common than first week and feces may contain blood. By zinabu D 62

Third week Patient continues to be febrile and increasingly exhausted. If no complications occur, patient begins to improve and temperature decreases gradually. By zinabu D 63

Clinical manifestations suggestive of typhoid fever Fever : Sustained fever (ladder fashion) Rose spots :Small pallor, blanching, slightly raised macules usually seen on chest and abdomen in the firstweek in 25% of white people. Relative bradycardia :slower than would be expected from the level of temperature. Leucopoenia: White cell count is less than 4000/mm3 of blood. By zinabu D 64

Diagnosis Based on clinical grounds but this is confused with wide variety of diseases. Serological examination : Widal test (reaction) against somatic and flagellar antigens(O or H) reactive Blood, feces or urine culture : Golden Dx for TF By zinabu D 65

Treatment Ciprofloxacin, 500mg P.O, BID for 10-14 days Alternative Amoxicillin,1g, P.O.QID , for children: 20 – 40mg/kg/day P.O.in 3 divided doses for 14 days OR Chloramphenicol , 500mg P.O QID, for 14 days: For children: 25mg/kg. OR By zinabu D 66

Cont, Sulfamethoxazole+trimethoprim , 800mg/160mg P.O.BID for 14 days. For children 6 weeks– 5 months, 100/20mg; 6 months – 5 yrs, 200/40mg; 6 – 12 yrs, 400/80mg BID For severe cases which are fluoroquinolone resistant: By zinabu D 67

Cont, Ceftriaxone , 1g QID as a single dose OR in 2 divided doses I.M. OR I.V. for 7-10 days. OR Chloramphenicol , 1g, IV bolus QID until 48 hrs after fever has settled, followed by 500mg P.O QID for a total of 14 days. For children : 25mg/kg, IV bolus QID, until 48 hrs after fever has settled, followed by 25mg/kg P.O.QID for a total of 14 days. By zinabu D 68

Cont, Adjunct Corticosteroid treatment: This is recommended only for patients with evidences of CNS involvement ( delirium, coma) Shock. By zinabu D 69

Cont, First line Dexamethasone , 3mg/kg IV initially, followed by 1mg/kg IV Q 6hrs for 48hrs total (This is prefered in patients with severe disease) OR Prednisolone , 20-40mg P.O. (or equivalent) once daily for the first three days of antibiotic treatment. By zinabu D 70

Nursing care Maintain body temperature to normal. Apply comfort measures. Follow side effects of drugs. Monitor vital signs. Follow strictly enteric precautions: Wash hands Wear gloves Teach all persons about personal hygiene By zinabu D 71

Cont, Observe the patient closely for sign and symptoms of: Bowel perforation Erosion of intestinal ulcers Sudden pain in the lower right side of the abdomen Abdominal rigidity Sudden fall of temperature and blood pressure Accurately record intake and output. Provide proper skin and mouth care. By zinabu D 72

Prevention and control Treatment of patients and carriers Education on handwashing , particularly food handlers,patients and childcare givers Sanitary disposal of feces and control of flies. Provision of safe and adequate water Safe handling of food. By zinabu D 73

Cont, Exclusion of typhoid carriers and patients from handling of food and patients Immunization for people at special risk ( e.g children &travelers to endemic areas) Regular check-up of food handlers in food and Drinking establishments By zinabu D 74

Bacillary Dysentery (Shigellosis) Is acute bacterial disease involving the large and distal small intestine, caused by the bacteria of the genus shigella . Infectious agent Shigella is comprised of four species or serotypes. Group A= Shigella dysentraie (most common cause) Group B= Shigella flexneri Group C= Shigella boydii Group D= Shigella sonnei By zinabu D 75

Epidemiology Occurrence - It occurs worldwide, and is endemic in both tropical and temperate climates. Outbreaks commonly occur under conditions of crowding and where personal hygiene is poor, such as in jails, institution s for children, day care centers, mental hospitals and refugee camps. By zinabu D 76

Cont, It is estimated that the disease causes 600,000 deaths per year in the world. Two-thirds of the cases, and most of the deaths, are in children under 10 years of age. Reservoir- Humans By zinabu D 77

Mode of transmission- Mainly by direct or indirect fecal-oral transmission from a patient or carrier. Transmission through water and milk may occur as a result of direct fecal contamination. Flies can transfer organisms from latrines to a non-refrigerated food item in which organisms can survive and multiply. By zinabu D 78

Cont, Incubation period- 12 hours-4 days (usually 1-3 days) Period of communicability: During acute infection and until the infectious agent is no longer present in feces, usually within four weeks after illness. By zinabu D 79

Susceptibility and resistance Is general. The disease is more severe in: Young Children, Elderly and the malnourished. Breast-feeding is protective for infants and Young children. By zinabu D 80

Clinical Manifestation Fever, rapid pulse , vomiting and abdominal cramp are prominent. Diarrhea usually appears after 48 hours with dysentery supervening two days later. Generalized abdominal tenderness . Tenesmus is present and feces are bloody, mucoid and Of small quantity. Dehydration is common and dangerous - it may cause muscular cramp, oliguria and shock. By zinabu D 81

Diagnosis Based on clinical grounds Stool microscopy (presence of pus cells) Stool culture confirms the diagnosis By zinabu D 82

Treatment Fluid and electrolyte replacement Co- trimoxazole 960 mg po bid for 10 day Doxaciclline 100mg po bid for 10 day Nalidixic acid, which is the most important especially for children. By zinabu D 83

Prevention and control Detection of carriers and treatment of the sick will interrupt an epidemic. Hand washing after toilet and before handling or eating food. Proper excreta disposal especially from patients, convalescent and carriers. Adequate and safe water supply. Control of flies. Cleanliness in food handling and preparation. By zinabu D 84

Amoebiasis (Amoebic Dysentery) An infection due to a protozoan parasite that Causes intestinalor extra-intestinal disease. Infectious agent Entamoeba histolytica By zinabu D 85

Epidemiology Occurrence: Worldwide but most common in the tropics and sub-tropics. Prevalent in areas with poor sanitation, in mental institutions and homosexuals. Invasive amoebiasis is mostly a disease of young people (adults). Rare below 5 years of age, especially below 2 years. By zinabu D 86

Mode of transmission Fecal-oral transmission by ingestion of food or water contaminated by feces containing the cyst. Acute amoebic dysentery poses limited danger. Incubation period: Variable from few days to several months or years; commonly 2-4 weeks By zinabu D 87

Cont, Period of communicability During the period of passing cysts of E.histolytica , which may continue for years. Susceptibility and resistance: General By zinabu D 88

Life cycle .. By zinabu D 89 TRANSMISSION 1.Cysts ingested in Food, water Or from hands contaminated with feces Environment. 6.Feces containing infective cysts contaminate the environment. HUMAN HOST 2. Cysts excyst , forming trophozoites 3. Multiply in intestine 4. Trophozoites encyst . 5. Infective cysts passed in feces.* * trophozoites passed in feces disintegrate

Clinical Manifestation Starts with a prodormal episode of : Diarrhea Abdominal cramps Nausea, vomiting and tenesmus . With dysentery, feces are generally watery, Containing mucus and blood. By zinabu D 90

Diagnosis Lab : Stool examination: Etamoeba histolytica cyst or trophozoite Treatment Metronidazole 500mg po tid for 07 day or Tinidazole 2gm po bid for 02 day By zinabu D 91

Prevention and control Adequate treatment of cases Provision of safe drinking water Proper disposal of human excreta (feces) and hand washing following defecation. Cleaning and cooking of local foods (e.g. raw vegetables) to avoid eating food contaminated with feces. By zinabu D 92

Giardiasis A protozoan infection principally of the upper small intestine associated with symptoms of chronic diarrhea, steatorrhea , abdominal cramps, bloating, frequent loose and pale greasy stools, fatigue and weight loss. Infectious agent Giardia lamblia By zinabu D 93

Epidemiology Occurrence- Worldwide distribution. Children are more affected than adults. The disease is highly prevalent in areas of poor sanitation. Reservoir- Humans Mode of transmission Person to person transmission occurs by hand to mouth transfer of cysts from feces of an infected individual especially in institutions and day Care centers. By zinabu D 94

Period of communicability Entire period of infection, often months. Susceptibility and resistance : Asymptomatic carrier rate is high. Infection is frequently self-limited. Persons with AIDS may have more serious and prolonged infection. By zinabu D 95

Life cycle . By zinabu D 96 TRANSMISSION 1. Cysts ingested in food, water or from hands contaminated with feces. HUMAN HOST 2 cysts excyst,forming trophozoites 3. Multiply in intestine 4. Trophozoites encyst . 5. Infective cysts passed in feces. * * trophozoites passed in feces disintegrate. ENVIRONMENT 6. Feces containing infective cysts contaminate the environment .

Clinical Manifestation Asymptomatic Severe failure to thrive and mal-absorption. Children usually have diarrhea but abdominal distension and bloating are frequent. Adults have : Abdominal cramps, diarrhea, Anorexia,nausea , malaise, Bloating, many Patients complain of sulphur testing (belching). By zinabu D 97

Diagnosis Stool examination : Cyst :Diagnostic stage Trophozoite :Rx in stage Treatment First Lline Tinidazole , single oral dose of 2g For children, 50-75mg/kg as a single dose Alternative Metronidazole , 250-500mg P.O., TID for five days By zinabu D 98

Prevention and control Good personal hygiene, and handwashing before food and following toilet use Sanitary disposal of feces Protection of public water supply from contamination of feces Case treatment Safe water supply By zinabu D 99

Cholera An acute illness caused by an enterotoxin elaborated by vibrio cholerae . Infectious agent Vibrio cholerae Epidemiology Occurrence : has made periodic outbreaks in different parts of the world and given rise to pandemics. Endemic predominantly in children. By zinabu D 100

Cont, Reservoir - Humans Mode of transmission- by ingestion of food or water directly or indirectly contaminated with feces or vomitus of infected person. Incubation period- from a few hours to 5 days, usually 2-3 days. By zinabu D 101

Period of communicability For the duration of the stool positive stage, usually only a few days after recovery. Antibiotics shorten the period of communicability. Susceptibility and resistance Gastric Achlorhydria increases risk of illness. Breast-fed infants are protected. By zinabu D 102

Clinical Manifestation Abrupt painless watery diarrhea; the diarrhea looks like rice water. In severe cases, several liters of liquid may be lost in few hours leading to shock. Severely ill patients are : Cyanotic, Have sunken eyes and cheeks, Scaphoid abdomen, poor skin turgor , and Thready or absent pulse. Loss of fluid continues for 1-7 days By zinabu D 103

Diagnosis Based on clinical grounds Lab : Culture (stool) confirmation By zinabu D 104

Treatment Objectives: Replace volume deficit and ongoing losses – Decrease duration of diarrhoea . For dehydration in mild cases: Give ORS, for children: < 2yrs: 50-100ml 2-10 years: 100-200ml after each loose stool. For severe cases Ringer lactate IV infusion (alternatively Normal saline) should be given 50-100ml/min until shock is reversed . KCl solution 20-40mmol/ litre may be added as required. By zinabu D 105

Pharmacologic First line Doxycycline , 100mg, P.O., BID for 3 days. For children: 6mg/kg daily for 3 days. Alternatives Tetracycline, 500mg P.O., QID for 3-5 days Sulfamethoxazole+trimethoprim , Children 6 weeks – 5 months: 100/20mg Children 6 months – 5 yrs: 200/40mg Children 6 – 12 yrs: 400/80mg BID for 5 days Adults: 800mg/160mg P.O., BID for 5 days. OR Ciprofloxacin, 500mg P.O., BID, for 3-5 days By zinabu D 106

Nursing care Wear gown and glove. Wash your hands. Monitor output including stool output. Protect the patient family by administering Tetracycline. Health education By zinabu D 107

Prevention and control Case treatment Safe disposal of human excreta and control of flies Safe public water supply Hand washing and sanitary handling of food Control and management of contact cases By zinabu D 108

Managing viral hepatitis An acute viral disease characterized by abrupt onset of: Fever,malaise Anorexia, nausea and Abdominal discomfort followed within a few days by Jaundice Infectious agent Type A, B, C, D & E virus Type :A is Epidemic hepatitis By zinabu D 109

Epidemiology Occurrence: Worldwide distribution in sporadic and Epidemic forms. Infection is common where environmental Sanitation is poor and occurs at an early age . Reservoir- Humans. By zinabu D 110

Mode of transmission Person to person by fecal-oral route. Through contaminated water and food contaminated byinfected food handlers. Incubation period: 15-55 days, average 28-30 days. By zinabu D 111

Period of communicability High during the later half of the incubation period continuing for few days following onset of jaundice. Most cases are non-infectious following first week of jaundice . Susceptibility and resistance : General.Immunity following infection probably lasts for life. By zinabu D 112

Clinical manifestation Abrupt onset of : Fever, malaise Anorexia, nausea and Abdominal discomfort, followed in few days by jaundice. Complete recovery without sequel or recurrence as a rule . By zinabu D 113

Diagnosis Based on clinical and epidemiological grounds Demonstration of IgM ( IgM anti-HAV) in the serum of acutely or recently ill patients. By zinabu D 114

Treatment Symptomatic : Rest High carbohydrate diet with low fat and protein By zinabu D 115

Prevention and control Public education about good sanitation and personal hygiene, with special emphasis on careful handwashing and sanitary disposal of feces. Proper water treatment and distribution systems and sewage disposal. Proper management of day care centers to minimize possibility of fecal-oral transmission. HA vaccine for all travelers to intermediate or highly endemic areas. Protection of day care centers’ employees by vaccine. By zinabu D 116

Hepatitis B Inflammation of liver caused by hepatitis B virus (HBV). WHO estimates above 2 billion person infected world wide with HBV of which 350 million are chronically infected and 1 million die per year. Etiology Hepatitis B virus (HBV) Reservoir Human By zinabu D 117

Mode of transmission Blood born transmission Sharing needles, toothbrush, razor blades, exposure to infected blood (transfusion), towels and close contact. Sexual transmission: - saliva, semen & vaginal fluid during kissing and sexual intercourse. By zinabu D 118

Cont, From mother to child: - at birth (mostly), during breast-feeding and intra- utero transmission. No faeco - oral transmission. No air borne transmission. Urine is not infective unless it contains blood. N.B: HBV is highly transmitted through parental way than HIV /AIDS. By zinabu D 119

Cont, Incubation period 45 – 160 days Period of communicability Extends over the period of acute illness that means it may last from few years to lifetime. 10% of patients become carriers. By zinabu D 120

Clinical manifestations Anorexia, nausea & vomiting Abdominal discomfort Arthralgia and rash Jaundice Chronically infected individuals may develop hepatoma (liver cancer), cirrhosis or chronic liver disease By zinabu D 121

Diagnosis Detection of hepatitis B surface antigen (HBSAG), which is present when the virus is in the blood in the acute stage & chronic carrier stage. By zinabu D 122

Treatment Drugs used in the treatment of hepatitis B include; Adefovir dipivoxil Interferon alfa - 2b, Pegylated interferon alfa - 2a, Lamivudine Entecavir Liver transplants may be beneficial to infected patients, but the virus remains in the body after transplantation surgery and may eventually attack the new liver. Alcohol is strictly for bidden because it increases the risk of cirrhosis. By zinabu D 123

Feces Mainly in Soil The diseases in this category are mainly transmitted through : Fecal contamination of soil. These infections are acquired through man’s exposure to focally contaminated soil. By zinabu D 124

Ascariasis A helminthic infection of the small intestine generally associated with few or no symptoms Infectious agent Ascaris lumbricoides . Epidemiology Occurrence: The most common parasite of humans wheresanitation is poor. School children (5-10 years of age) are most affected. Highly prevalent in moist tropical countries 125

Cont, Reservoir: Humans ascarid eggs in soil. Mode of transmission: Ingestion of infective eggs from soil contaminated with human feces or uncooked Produce contaminated with soil containing infective eggs but not directly from person to person or from fresh feces. By zinabu D 126

Cont, Incubation period- 4-8 weeks Period of communicability : As long as mature fertilized female worms live in the intestine. Usual life span of the adult worm is 12 months . By zinabu D 127

Cont, Susceptibility and resistance : Is general By zinabu D 128

Life Cycle . By zinabu D 129 TRANSMISSION 1.Infective eggs ingested in food or from contaminated hands HUMAN HOST 2. Larvae hatch.Migrate through liver and lungs. 3. Pass up trachea and are swallowed 4. Become mature worms in small intestine 5. Eggs produced and passed in feces. ENVIRONMENT 6. Eggs become infective ( embryonated ) in soil in 30-40 days. 7. Infective eggs contaminate theenvironment .

Clinical Manifestation Most infections go unnoticed until large worm is passed in feces and occasionally the mouth and nose. Migrant larvae may cause: Itching, wheezing Dyspnea,fever and productive cough with bloody sputum may occur . By zinabu D 130

Cont, Abdominal pain may arise from intestinal or duct ( biliary,pancreatic ) obstruction. Serious complications include: Bowel obstruction due to knotted/intertwined worms . By zinabu D 131

Diagnosis Microscopic identification of eggs in a stool sample Adult worms passed from anus, mouth or nose . By zinabu D 132

Treatment First line: Albendazole , 400mg P.O. as a single dose, for children: 1 – 2 years, 200mg as a single dose. Mebendazole , 100mg P.O.BID for 3 days or 500mg, once Alternative (pregnant women) Pyrantel pamoate , 700mg P.O as a single dose By zinabu D 133

Prevention and control Treatment of cases Sanitary disposal of feces Prevent soil contamination in areas where children play Promote good personal hygiene( handwashing ). By zinabu D 134

Trichuriasis A nematode infection of the large intestine, usually asymptomatic in nature. Infectious agent Trichuris trichuria (whip worm) Found in (adult) caecum and vermiform appendix Epidemiology Occurrence: Worldwide, especially in warm moist regions. Common in children 3-11 years of age. By zinabu D 135

Cont, Reservoir - Humans Mode of transmission : Indirect, particularly through pica or ingestion of contaminated vegetables. Incubation period: Indefinite Period of communicability: Several years in untreated carriers. Susceptibility and resistance: Is universal By zinabu D 136

Life Cycle . By zinabu D 137 TRANSMISSION 1. Infective eggs ingested in food or from contaminated hands HUMAN HOST 2. Larvae hatch. Develop in small intestine. Migrate to caecum . 3. Become mature worms. 4. Eggs produced and passed in feces. ENVIRONMENT 6. Eggs become infective ( embryonated ) in soil after 3weeks. 7. Infective eggs contaminate the environment

Clinical manifestation Severity is directly related to the number of infecting worms. Most infected people are asymptomatic. Abdominal pain, tiredness, nausea and vomiting, diarrhea or constipation are complaints by patients. Rectal prolapse may occur in heavily infected very young children By zinabu D 138

Diagnosis Demonstration of eggs in feces Treatment Mebendazole , 500mg P.O., single dose OR Albendazole , 400mg,P.O. for three days By zinabu D 139

Prevention and control Sanitary disposal of feces Maintaining good personal hygiene (i.e. washing hands and vegetables and other soil contaminated foods) Cutting nails especially in children Treatment of cases. By zinabu D 140

Entrobiasis A common intestinal helminthic infection that is often asymptomatic. Infectious agent Entrobius vermicularis ( Oxyuriasis , pinworm infection) By zinabu D 141

Epidemiology Occurrence : Worldwide, affecting all socio-economic classes with high rates in some areas. Prevalence is highest in school-aged children, followed by preschools and is lowest in adults except for mothers of infected children. Prevalence is often high in domiciliary institutions. Infection usually occurs in more than one family member. By zinabu D 142

Cont, Reservoir- Human Mode of transmission- Direct transfer of infective eggs by hand from anus to mouth of the same or another person or indirectly through clothing, bedding, food or other articles contaminated with eggs of the parasite. By zinabu D 143

Cont, Incubation period: 2-6 weeks Period of communicability: As long as gravid females are discharging eggs on perianal skin. Eggs remain infective in an indoor environment for about 2 weeks. Susceptibility and resistance: universal . By zinabu D 144

Life Cycle . By zinabu D 145 Adult worms in Caecum Gravid females migrate through the anus to the perianal skin and deposit eggs (usually during the night) Eggs become infective in a few hours in perianal area Migrate down To caecum Ingestion of eggs by Man Larvae hatch in duodenum 2-3 weeks

Clinical manifestation Perianal itching, Disturbed sleep, irritability and some times secondary infection of the scratched skin. By zinabu D 146

Diagnosis Stool microscopy for eggs or female worms. Treatment First line-options Mebendazole , 100mg P.O. BID for 3 days OR Albendazole , 400mg P.O. as a single dose Alternative Piperazine , 4g in a single dose. By zinabu D 147

Prevention and control Educate the public about hygiene (i.e. hand Washing before eating or preparing food, keeping nails short and discourage nail biting). Treatment of cases Reduce overcrowding in living accommodations. Provide adequate toilets. By zinabu D 148

Strongyloidiasis An often asymptomatic helminthic infection of the duodenum and upper jejunum. Infectious agent Strongyloides stercolaris Epidemiology Occurrence: Commonly occurs as opportunistic infection In tropical and temperate areas. More common in warm and wet regions. By zinabu D 149

Cont Reservoir - Human Mode of transmission- Infective ( filariform ) larvae penetrate the skin and enter the venous circulation. By zinabu D 150

Cont, Incubation period- 2-4 weeks (from skin penetration up towhen rhabditi form larvae appear in the feces). Period of communicability- As long as living worms remain in the intestine; up to 35 years in cases of auto-infection. By zinabu D 151

Cont, Susceptibility and resistance: is universal. Patients with AIDS or on immuno -suppressive medication are at risk of dissemination. By zinabu D 152

Life Cycle . By zinabu D 153 TRANSMISSION 1. Infective filariform larvaepenetrate skin, e.g. feet. Autoinfection also occurs. HUMAN HOST 2. Larvae migrate, pass up trachea and are swallowed. 3. Become mature worms in small intestine 4. Eggs laid. Hatch rhabditiform larvae in intestine. 5. Rhabditiform larvae: - Passed in feces, or - Become filariform larvae in intestine, causing atutoinfection .. ENVIRONMENT 6. In soil larvae become freeliving worms produce more rhabditiform larvae* * Free-living cycle can be repeated several times 7. Become infective filariform larvae in the soil

Clinical Manifestation Pneumonia occurs during heavy larval migration. Mild peptic ulcer like epigastric discomfort to Severe watery diarrhea. Heavy infection may result in malabsorption syndrome . By zinabu D 154

Cont, Diagnosis Identification of larvae in stool specimen . Treatment First line Ivermectin , 200mg/kg daily for 2 days. Alternatives Albendazole 400mg P.O.BID for three consecutive days. OR Thiabendazole , 1500mg, P.O. BID,for 3day for children: 25mg/kg p.o . for three consecutive days. By zinabu D 155

Prevention and control Proper disposal of human excreta (feces) Personal hygiene including use of footwear. Case treatment. By zinabu D 156

Hookworm disease A common chronic parasitic infection with a variety of symptoms usually in proportion of the degree of anemia. Infectious agent Nematode of Intestine Ancyclostoma duodenale - less common than N. Americans Necator Americanus : Common in western hemisphere In all parts of tropics like Far East, South Asia, Tropical Africa (like Ethiopia) By zinabu D 157

Epidemiology Occurrence - Widely endemic in tropical and subtropical countries where sanitary disposal of human feces is not practiced and the soil moisture and temperature conditions favor development of Infective larvae. Reservoir - Humans By zinabu D 158

Cont. Mode of transmission- Through skin penetration by infective larvae Ingesting filariform larvae Incubation period- Symptoms may develop after a few weeks to many months depending on intensity of infection and iron intake of the host . By zinabu D 159

Cont, Period of communicability- Infected people can Contaminate the soil for several years in the absence of treatment. Susceptibility and resistance- Is universal. No evidence that immunity develops with infection . By zinabu D 160

Life cycle . By zinabu D 161 TRANSMISSION 1. Infective filariform larvae penetrate theskin , e.g. feet. A. duodenale also transmitted by ingestion of larvae HUMAN HOST 2. Larvae migrate. Pass up trachea and are swallowed. 3. Become mature worms in small intestine (attach to wall and suck blood). 4. Eggs produced and passed in feces. ENVIRONMENT 5. Eggs develop; Rhabditiform larvae hatch. Feed in soil. 6. Develop into infective filariform larvae in about 1 week. 7. Filariform larvae contaminate soil.

Clinical Manifestation The clinical manifestation is related to: Larval migration of the skin Produces transient, localized maculo papular rash associated with itching called ground itch. Migration of larva to the lungs. Produces cough, wheezing and transient pneumonitis . By zinabu D 162

Cont, Blood sucking Light infection-no symptoms Heavy infection-result in symptoms of peptic ulcer disease like epigastric pain and tenderness. Further loss of blood leads to anemia manifested by exertional dyspenea , weakness and light- headedness . By zinabu D 163

Cont Diagnosis Demonstration of eggs in stool specimen Treatment First line-options Mebendazole , 100mg P.O. BID for 3 days or 500mg stat OR Albendazole , 400mg P.O. as a single dose. Alternatives: Pyrantel pamoate , 700mg P.O. as a single dose By zinabu D 164

Prevention and control Sanitary disposal of feces Wearing of shoes Case treatment. By zinabu D 165

Direct Contact with Feces Are diseases transmitted mainly through direct contact with feces of the infected person . Poliomyelitis A viral infection most often recognized by the acute onset of flaccid paralysis. Infectious agent Polio viruses (type I, II and III) By zinabu D 166

Epidemiology Occurrence – Worldwide prior to the advent of immunization. Cases of polio occur both sporadically and in epidemics. Primarily a disease of infants and young children. 70-80% of cases are less than three years of age. More than 90% of infections are unapparent. Flaccid paralysis occurs in less than 1% of infections. By zinabu D 167

Cont, Reservoir – humans, especially children Mode of transmission- Primarily person-to- person, spread principally through the fecal-oral route. In rare instances, milk, food stuffs and other materials contaminated with feces have been incriminated as vehicles. By zinabu D 168

Cont Incubation period- commonly 7-14 days Period of communicability – not precisely known, buttransmission is possible as long as the virus is excreted. Susceptibility and resistance- Is common in children but paralysis rarely occurs. Infection confers permanent immunity. By zinabu D 169

Clinical manifestation Usually asymptomatic or non-specific fever is manifestedin 90% of cases. If it progresses to major illness, severe muscle pain, stiff neck and back with or without flaccid paralysis may occur. Paralysis is asymptomatic and occurs within three to fourd ays of illness. The legs are more affected than other part of the body. Paralysis of respiratory and swallowing muscles is life threatening . By zinabu D 170

Cont, Diagnosis Based on clinical and epidemiological grounds Treatment Symptomatic Prevention and control Educate public about the advantage of immunization in early childhood. Trivalent live attenuated vaccine (OPV) at birth. Safe disposal of human excreta (feces). By zinabu D 171

Hydatid Disease ( Echinococcosis ) The tapeworm Echinococcus granulosus is the most common species of Echinococcus and causes cystic hydatid disease. Infectious agent Echinococcus granulosus , a small tapeworm of dog By zinabu D 172

Epidemiology Occurrence – occurs on all continents except Antarctica. Especially common in grazing countries where dogs consume viscera containing cysts. Reservoir - Domestic dogs are definitive hosts; they may harbor thousands of adult tapeworms in their intestines without signs of infection. Sheep act as intermediate hosts. By zinabu D 173

Cont, Mode of transmission – directly with hand to mouth transfer of eggs after association with infected dogs or indirectly through contaminated food, water, soil or fomites . By zinabu D 174

Cont, Incubation period – variable from 12 months to many years, depending on the number and location of cysts and how rapidly they grow. Period of communicability – Infected dogs begin to pass eggs approximately 7weeks after infection. Most canine infections resolve spontaneously by six months. By zinabu D 175

Cont, Susceptibility and resistance : Children are more likely to be exposed to infection because they are more likely to have close contact with infected dogs. By zinabu D 176

Clinical manifestations The signs and symptoms vary according to location of the cyst and number. Ruptured or leaking cysts can cause severe anaphylactic reactions. Cysts are typically spherical, thick walled and unilocular and are most frequently found in the liver and lungs. By zinabu D 177

Diagnosis History of residence in an endemic area along with association with canines Sonography and CT scan Serologic test By zinabu D 178

Treatment Multi cyst not amenable to surgery may respond to: Flumebendazol 2gm daily for 10-12 months or Prolonged Albendazole therapy, Surgical resection of isolated cysts is the most common treatment. By zinabu D 179

Prevention and control Educate the public at risk to avoid exposure to dog feces. Handwashing should be emphasized. Interrupt transmission from intermediate to definitive hosts by preventing dogs’ access to uncooked viscera. Safe disposal of infected viscera. Periodical treatment of high-risk dogs. By zinabu D 180

Quiz 1.What does fecal-oral transmission mean? 2.Mention some of the diseases transmitted through unapparent fecal contamination of food, water and hands. 3.State some of the common preventive and control measures of oral-fecal transmitted diseases. By zinabu D 181

By zinabu D 182 Thank You!!

CHAPTER 3 AIR-BORNE DISEASES Zinabu D( Bsc )

Learning Objectives At the end of this chapter, students will be able to: List common air-borne diseases. Identify the common modes of air-borne diseases transmission. Participate in diagnosis and treatment of common air borne diseases. Apply preventive and control methods for air- borne diseases.

INTRODUCTION The organisms causing the diseases in the air-borne group enter the body via the respiratory tract. When a patient or carrier of pathogens talks, coughs, laughs, or sneezes, he/she discharges fluid droplets.

Cont, The smallest of these remain up in the air for some time and may be inhaled by a new host. Droplets with a size of 1-5 microns are quite easily drawn in to the lungs and retained there.

Cont, Droplets that are bigger in size will not remain air borne for long but will fall to the ground. Here, however, they dry and mix with dust. When they contain pathogens that are able to survive drying, these may become air-borne again by wind or some thing stirring up the dust, and they can then be inhaled.

Cont, Air-borne diseases, obviously, will spread more easily when there is overcrowding, as in overcrowded class rooms, public transport, canteens, dance halls, and cinemas. Good ventilation can do much to counteract the effects of overcrowding. Air-borne diseases are mostly acquired through the respiratory tract.

1.Common Cold An acute catarrhal infection of the upper respiratory tract. Infectious agent Rhino viruses (100 serotypes) are the major causes in adults. Parainfluenza viruses, respiratory syncytial viruses (RSV) Influenza, and Adeno viruses cause common cold-like illnesses in infants and children.

Epidemiology Occurrence- Worldwide both in endemic and epidemic forms. Many people have one to six colds per year. Greater incidence in the highlands. Incidence is high in children under 5 years and gradually declines with increasing age.

Cont, Reservoir - Humans Mode of transmission- by direct contact or inhalation of airborne droplets. Indirectly by hands and articles freshly soiled by discharges of nose and throat of an infected person.

Cont, Incubation period - between 12 hours and 5 days, usually 48 hours, varying with the agent. Period of communicability- 24 hours before onset and for 5 days after onset. Susceptibility and resistance- is universal. Repeated infections (attacks) are most likely due to multiplicity of agents.

Clinical Manifestation Coryza , sneezing, lacrimation , pharyngeal or nasal irritation, chills and malaise dry or painful throat. Diagnosis Based on clinical grounds

Treatment No effective treatment but supportive measures Like: Bed rest Steam inhalation High fluid intake Anti pain Balanced diet intake

Prevention and Control I.Educate the public about the importance of: Handwashing Covering the mouth when coughing and sneezing Sanitary disposal of nasal and oral discharges II,Avoid crowding in living and sleeping quarters especially in institutions III.Provide adequate ventilation

2.Measles An acute highly communicable viral disease Infectious agent Measles virus

Epidemiology Occurrence :Prior to widespread immunization, measles was common in childhood so that more than 90% of people had been infected by age 20; few went through life without any attack.

Cont, Reservoir - Humans Mode of transmission- Airborne by droplet spread, direct contact with nasal or throat secretions of infected persons and less commonly by articles freshly solid with nose and throat secretion. Greater than 94% herd immunity may be needed to interrupt community transmission.

Cont, Incubation period- 7-18 days from exposure to onset of fever. Period of communicability- slightly before the prodromal period to four days after the appearance of the rash and minimal after the second day of rash.

Cont Susceptibility and resistance- All those who are non vaccinated or have not had the disease are susceptible. Permanent immunity is acquired after natural infection or immunization .

Clinical Manifestation Prodromal fever, conjunctivitis, coryza , cough and Koplik spots on the buccal mucosa A characteristic red blotchy rash appears on the third to seventh day, beginning on the face, gradually becoming generalized, lasting 4-7 days. Leucopoenia is common. Complications like otitis media, pneumonia, diarrhea, encephalitis, croup ( Laryngo tracheo bronchitis) may result from viral replication or bacterial super infection.

Cont, Diagnosis Based on clinical and epidemiological grounds Treatment No specific treatment Treatment of complications Vitamin A provision

Cont, Nursing care Advise patient to have bed rest. Relief of fever. Provision of non-irritant small frequent diet. Shorten the fingernails.

Prevention and control Educate the public about measles immunization. Immunization of all children (less than 5 years of age)who had contact with infected children. Provision of measles vaccine at nine months of age. Initiate measles vaccination at 6 months of age during epidemic and repeat at 9 months of age.

3.Influenza An acute viral disease of the respiratory tract Infectious agent Three types of influenza virus (A,B and C) Epidemiology Occurrence- In pandemics, epidemics and localized outbreaks. Reservoir - Humans are the primary reservoirs for human infection.

Cont, Mode of transmission- Airborne spread predominates among crowded populations in closed places such as school buses. Incubation period- short, usually 1-3 days

Cont Period of communicability- 3-5 days from clinical onset in adults; up to 7 days in young children. Susceptibility and resistance- when a new sub type appears, all children and adults are equally susceptible. Infection produces immunity to the specific infecting agent.

Clinical Manifestation Fever, head ache, mayalgia , prostration, sore throat and cough Cough is often severe and protracted, but other manifestations are self-limited with recovery in 2-7days Diagnosis Based on clinical ground

Treatment Same as common cold, namely: Anti-pain and antipyretic High fluid intake Bed rest Balanced diet intake

Prevention and control I. Educate the public in basic personal hygiene, especially the danger of unprotected coughs and sneezes and hand to mucus membrane transmission. II. Immunization with available killed virus vaccines may provide 70-80% protection. III. Amantadize hydrochloride is effective in the chemprophylaxis of type A virus but not others

4.Diphtheria An acute bacterial disease involving primarily tonsils, pharynx,nose , occasionally other mucus membranes or skin and sometimes the conjunctiva or genitalia. Infectious agent Corynebacterium diphtheriae

Epidemiology Occurrence - Disease of colder months in temperate zones, involving primarily non-immunized children under 15 years of age. It is often found among adult population groups whose immunization was neglected. Unapparent, cutaneous and wound diphtheria cases are much more common in the tropics.

Cont, Reservoir - Humans Mode of transmission- contact with a patient of carrier. i.e.with oral or nasal secretions or infected skin. Incubation period- usually 2-5 days Period of communicability- variable, until virulent bacilli have disappeared from discharges and lesion; usually 2 weeks or less.

Cont, Susceptibility and resistance- Is universal. Infants borne to immune mothers are relatively immune, but protection is passive and usually lost before months.Recovery from clinical disease is not always followed by lasting immunity. Immunity is often acquired through unapparent infection. Prolonged active immunity can be induced by diphtheria toxoid .

Clinical Manifestation Characteristic lesion marked by a patch or patches of an adherent grayish membrane with a surrounding inflammation (pseudo membrane). Throat is moderately sore in pharyngo tonsillar diphtheria,with cervical lymph nodes somewhat enlarged and tender; in severe cases, there is marked swelling and edema of neck.

Cont Late effects of absorption of toxin appearing after 2-6 weeks, including cranial and peripheral, motor and sensory nerve palsies and myocarditis (which may occur early) and are often severe.

Diagnosis Based on clinical and epidemiological grounds Bacteriologic examination of discharges from lesions.

Treatment Diphtheria antitoxin Erythromycin for 2 weeks but 1 week for cutaneous form or Procaine penicillin for 14 days or single dose of Benzathin penicillin Primary goal of antibiotic therapy for patients or carriers is to eradicate C. diphtheriae and prevent transmission from the patient to susceptible contacts.

Prevention and control Educate the public, and particularly the parents of young children, of the hazards of diphtheria and the necessity for active immunization. Immunization of infants with diphtheria toxoid . Concurrent and terminal disinfection of articles in contact with patient and soiled by discharges of patient. Single dose of penicillin (IM) or 7-10 days course of Erythromycin (PO) is recommended for all persons exposed to diphtheria.

5.Pertusis (whooping cough) An acute bacterial disease involving the respiratory tract. Infectious agent Bordetella pertusis Epidemiology Occurrence - An endemic disease common to children especially young children everywhere in the world. A marked decline has occurred in incidence and mortality rates during the past four decades. Outbreaks occur periodically. Endemic in developing world and 90% of attacks occur in children under 6 years of age.

Cont, Reservoir- Humans Mode of transmission- Primarily by direct contact with discharges from respiratory mucus membranes of infected persons by airborne route, probably by droplets. Indirectly by handling objects freshly solid with nasopharyngeal secretions.

Cont, Incubation period- 1-3 weeks Period of communicability: Highly communicable in early catarrhal stage before the paroxysmal cough stage. The most contagious disease with an attack rate of 75-90%. Gradually decreases and becomes negligible in about 3 weeks. When treated with erythromycin, infectiousness is usually 5 days orless after onset of therapy .

Cont, Susceptibility and resistance: Susceptibility to non immunized individuals is universal. One attack usually confers prolonged immunity but may not be lifelong.

Clinical manifestation The disease has insidious onset and 3 phases: I. Catarrhal phase Lasts 1-2 weeks Cough and rhinorrhea II Paroxysmal phase Explosive, repetitive and prolonged cough Child usually vomits at the end of paroxysm Expulsion of clear tenacious mucus often followed by vomiting

Cont, Whoop ( inspiratory whoop against closed glottis) between paroxysms. Child looks healthy between paroxysms Paroxysm of cough interferes with nutrition Cyanosis and sub conjunctiva hemorrhage due to violent cough.

Cont, III.Convalescent phase The cough may diminish slowly or may last long time. After improvement the disease may recur.

Diagnosis History and physical examination at phase two (paroxysmal phase) ensure the diagnosis. Marked lymphocytosis . Treatment 1.Erythromycin- to treat the infection in phase one but to decrease transmission in phase two 2. Antibiotics for super infections like pneumonia because of bacterial invasion due to damage to cilia

Nursing care Proper feeding of the child. Encourage breastfeeding immediately after an attack(each paroxysm). Proper ventilation- continuous well humidified oxygen administration. Reassurance of the mother (care giver),

Prevention and control I. Educate the public about the dangers of whooping cough and the advantages of initiating immunization at 6 weeks of age. II. Consider protection of health workers at high risk of exposure by using erythromycin for 14 days.

6.Pneumococcal pneumonia An acute bacterial infection of the lung tissue and bronchi Infectious agent Streptococcus pneumoniae ( pneumococcus ) Epidemiology Occurrence- Endemic particularly in infancy, old age and persons with underlying medical conditions. Epidemics can occur in institutions, barracks and on board ship where people are living and sleeping in close quarters. Common in lower socio-economic groups and developing countries .

Cont, Reservoir- Humans : Pneumococci are usually found in the URT of healthy people throughout the world.

Mode of transmission Droplet spread, direct oral contact or indirectly through articles freshly soiled with respiratory discharges. Person to person transmission is common. Incubation period- not well determined, may be as short as 1-3 days. Period of communicability- Until discharges of mouth and nose no longer contain virulent pneumococci in significant number.

Cont, Susceptibility and resistance: Susceptibility is increased by influenza, pulmonary edema of any cause, aspiration following alcohol intoxication, chronic lung disease, &exposure to irritants in the air. Malnutrition and low birth weight are important risk factors in infants and young children in developing countries. Immunity following an attack may last for years.

Clinical Manifestation Sudden onset of chill, fever, pleural pain, Dyspnea,tachypnea , a Cough productive of rusty Sputum,chest indrawing , shallow and Rapid respiration in infants and young children. Vomiting and convulsion may occur in infants and young children.

Diagnosis Based on clinical grounds Chest X-ray- reveals consolidation of the affected lung tissue but not in children. Sputum gram stain- reveals gram negative diplococci .

Treatment Community acquired ambulatory patients (Mild Pneumonia): Clarithromycin , 500mg P.O. BID for 5-7 days OR Azitromycin , 500mg P.O first day then 250mg P.O., for 4d. PLUS Amoxicillin, 1000mg P.O., TID for 5 to 7 days. OR Amoxicillin- clavulanate , 625mg P.O., TID for 5-7days Or Doxycycline , 100mg P.O., BID for 7-10 days (Not ordered for PW)

Cont, Community acquired hospitalized patients (Severe Pneumonia) Ceftriaxone , 1g I.V. OR I.M every 12-24 hours for 7 days. OR Benzyl penicillin, 2-3 million IU I.V. QID for 7-10 days. PLUS Azithromycin , 500mg on day 1 followed by 250mg/day on days 2 – 5day or Clarithromycin , 500mg P.O., BID for 7-10 days

Empiric treatment for commonly suspected etiologies of HAP First line Ceftazidime , 1gm I.V. TID for 10-14days PLUS Vancomycin 1g I.V. BID for 10-14 days Alternatives Ceftriaxone , 1-2g I.V. OR I.M. BID for 7 days. PLUS Gentamicin , 3-5mg/kg I.V. QDdaily in divided doses for 7 days. OR Ciprofloxacin, 500mg P.O./I.V. BID every 12 hours for 7 days .

Nursing care Monitor vital signs especially of children. Maintain high body temperature to normal. Intermittent administration of humidified oxygen if indicated especially for young children. Timely administration of ordered medication.

Prevention and control Treatment of cases Treatment of other underlying medical conditions Improved standard of living (adequate and ventilated housing and better nutrition) Avoid overcrowding.

7.Meningococcal Meningitis What is meningitis?

Cont, An inflammation of the tissue of the meninges An acute bacterial disease that causes inflammation of the pia and arachnoid space. A general name for inflammation of a) meninges sheaths that cover the brain and spinal cord. b) cerebrospinal fluid The fluid that circulates in the spaces in and around the brain and spinal cord.

Cont,

Types of Meningitis Viral Meningitis Caused by virus . Less severe Resolves without specific treatment within a week or 2 week Also called as aseptic meningitis Eg : Enteroviruses coxsackie virus, echovirus, HSV-2, etc Bacterial Meningitis Caused by bacteria Quite severe and may result in a) brain damage b) hearing loss c) learning disability It would also causes death!

Cont, Etiologic agent Bacterial Viral Fungus 1.Neisseria meningitis ( meningococcous ) Common in adults and children 2. Streptococcous pneumonia ( pneumoccous ) Common in adults 3. Hemophilus influenza Common under 5 years of ag e

Epidemiology Occurrence - Greatest incidence occurs during winter and spring. Epidemics occur irregularly. Common in children and young adults. It is also common in crowded living conditions.

Cont, Reservoir - Humans Mode of transmission- Direct contact with respiratory droplets from nose and throat of infected person . Risk factors Sero -type -subgroup A cause historically epidemic meningitis Nasopharyngeal carriage Low humidity (dry) and dust enhance transmission Travel , migration and gathering together Poor living condition

Cont, Incubation period- 2-10 day, commonly 3-4 days. Period of communicability- as long as the bacteria is present in the discharge. Susceptibility and resistance Susceptibility is low and decreases with age

Cont, Symptoms are result from infection and increased intracranial pressure (IICP) Fever Altered consciousness, irritability, photophobia Seizures 20 - 30% of the cases Bulging fontanel 30%

Cont, Sign are result from infection and increased intracranial pressure(IICP) Change in vital sign (Cushing’s triad (HTN, brady cardia , irreg resp ) ) Headache Projectile Vomiting, poor appetite Decreased level of consciousness Cranial nerve palsies Coma

Cont,

Cont, N.B Meningismus (stiff neck + Brudzinski + Kernig signs) Positive Brudzinski sign – flex the neck while the patient in supine position with extremities extended. Patient neck is flexed , involuntary flexion of leg & knees occur or passive flexion of leg cause similar movement of the other

Cont, Positive Kernig sign – in a supine patient flex the hip to 90  while the knee is flexed at 90  , an attempt to further extend of the knees produce pain in the hamstrings back or neck and resistance to further extension.

Cont,

Diagnosis Clinical and epidemiological ground CSF analysis – the corner stone in the the diagnosis of meningitis is examination of the CSF In general , whenever the diagnosis of meningitis is strongly considered , promptly perform a Lumbar puncture Measure the opening pressure and send the fluid for cell count (and differential count ) ,chemistry ( i.e CSF glucose,and protien ), and microbiology ( i.e gram stain and culture ) CT scan of the brain may be done prior to lumbar puncture in some patients with a high risk of herniation

Cont, Needle with stylet inserted into the subarachnoid space between L3-4 or L4-5. Styleted needle used so as to not introduce a plug of epidermal cells into the space which may later grow into a cord-compressing epidermoid tumor.

lumbar puncture

Contraindications to Lumbar Puncture Respiratory distress (positioning)  ICP reported to increase risk of herniation Cellulitis at area of tap Bleeding disorder

CSF evaluation Condition WBC L Protein (mg/dL) Glucose (mg/dL) Normal <7, lymphs mainly 5-45 >50 Bacterial, acute 100 – 60 100-500 Low Bacterial 1 – 10,000 100+ Low to normal TB 10 – 500 100-500 <50 Fungal 25 – 500 25-500 <50 Viral <1000 50-100 Normal

Cont,

Treatment A.Community acquired, bacterial etiology unknown First line Ceftriaxone , 4g/day, I.V., divided in 2 doses for 10-14 days PLUS Vancomycin , 1gm IV BID for 10-14days Alternative Benzyl penicillin, 20-24 million IU/day I.V. in 4-6 divided doses for 7 –10 days. PLUS Chloramphenicol , 500mg I.V. QID. In severe infections, up to 100mg/kg/day in 4 divided doses, may be used for 7 days

B. Empiric treatment, hospital acquired meningitis, related to post-neurosurgery lumbar catheter &penetrating trauma First line Vancomycin , 15mg/kg IV Q8h PLUS Ceftazidime , 2g IV q8h Alternative Vancomycin , 15mg/kg IV Q8h PLUS Meropenem , 2gm IV Q8hr

C. Immunosuppressed (HIV positive, uncontrolled diabetes, patients taking high dose Dexamethasone , 10mg IV QID for 4 days PLUS Ceftazidime , 2g IV q8h PLUS Vancomycin , 15mg/kg IV Q8h PLUS Ampicillin , 2g IV q4h PLUS Acyclovir 10mg/kg (infuse over 1h) Q8h for 14-21d

Complications of Meningitis One of the most common problems resulting from meningitis is hearing loss . Anyone who has had meningitis should take a hearing test . Young children: Babyish behavior Forgetting recently learned skills Reverting to bed-wetting Babyish behavior

Cont, Older people: Lethargy Recurring headaches Difficulty in concentration Short-term memory loss Balance problems Depression

Serious complications Brain damage Epilepsy Changes in eye sight

Nursing care Maintain fluid balance (input and output) Maintain body temperature to normal Timely administration of antibiotics Monitor vital signs.

Prevention and control Educate the public on the need to reduce direct contact and exposure to droplet infection. Reduce overcrowding in work places, schools,& camps, Vaccines containing group A,C and Y strains. Chemotherapy of cases. Chemo prophylaxis ( e.g.Rifampin for 2 days) Report to the concerned health authorities.

8.Tuberculosis

Tuberculosis A chronic and infectious mycobacterial disease important as a major cause of illness and death in many parts of the world. Is an air borne communicable disease caused by bacteria from Mycobacterium tuberculosis complex.

Cont, Infectious agent Mycobacterium tuberculosis- human tubercle bacilli (commonest cause) Mycobacterium bovis - cattle and man infection Mycobacterium avium - infection in birds and man .

Epidemiology Occurrence Worldwide, however underdeveloped areas are more affected. Affects all ages and both sexes. Age groups between 15-45 years are mainly affected. According to the WHO 1995 report, 9 million cases and 3 million deaths have occurred. According to the Ministry of Health report in 1993 E.C, tuberculosis was a leading cause of outpatient morbidity (ranked 8th with 2.2% ), leading cause of hospitalization (ranked 3rd with 7.8%) and leading cause of hospital death (ranked 1st with 10.1%).

Cont, Tuberculosis has two major clinical forms. Pulmonary (80% ) primarily occurs during childhood and secondarily 15-45 years or later. The other is extra pulmonary, which affects all parts of the body. Most common sites are lymph nodes, pleura, genitourinary tract, bone and joints, meninges and peritoneum.

Cont, Mode of transmission- Through aerosolized droplets mainly from persons with active ulcerative lesion of lung expelled during talking, sneezing, singing, or coughing directly. Untreated pulmonary tuberculosis positive (PTB+) cases are the source of infection. Most important is the length of time of contact an individual shares volume of air with an infectious case. That is intimate, prolonged or frequent contact is required.

Cont, Transmission through contaminated fomites (clothes, personal articles) is rare. Ingestion of unpasteurized milk transmits bovine tuberculosis. Overcrowding and poor housing conditions favor the disease transmission. I ncubation period- 4-12 weeks Period of communicability- as far as the bacilli is present in the sputum

Susceptibility and resistance Under 3 years old children, adolescents, young adults, the very old and the immuno suppressed are susceptible. Everyone who is non-infected or non-vaccinated can be infected.HIV is an important risk factor for the development of HIV associated tuberculosis by facilitating: Reactivation or Progression of recent infection or Reinfection

Pathogenesis Infection establishes when the bacillus is recognized by the immune cells of the susceptible individual. Once the bacilli start multiplication, it spreads through the blood stream and seeds in multiple organs, which later may evolve into extrapulmonary TB.

Cont, After 6-8weeks, the immune system starts to contain the multiplication and in most instances manages to stop further multiplication and remain as latent infection . While in few patients, the multiplication continues and directly progress to active disease (primary TB), mainly in person with compromised immunity.

Cont, The latent infection may be reactivated into active TB (secondary TB) later in life, if the person encounters conditions that compromise cell-mediated immunity. Disease usually occurs in the lungs (pulmonary TB). However, haematogenic dissemination can cause it also to occur in other parts of the body (extra-pulmonary TB). If massive haematogenic dissemination occurs, all organs can be affected ( miliary TB).

Evolution of latent and active TB Latent TB Infection (LTBI): refers to the stage whereby the immune system of the person halt the multiplication of the bacilli and tissue damage, and hence, no symptoms presents. Active TB disease refers : to the conditions whereby the person with TB infection starts to present with clinical presentation of TB that requires full course multi-drug chemotherapy.

Cont, Primary TB : occurs in 5-10% of case when active TB develops immediately after infection usually within 1-2 years after exposure. Common in children and other immuno suppressed individuals Post-primary/secondary TB : refers to active TB that is a result of reactivation of endogenous latent foci, which remained dormant since the initial infection.

Differences between latent TB infection and active TB disease Characteristics Latent TB Infection Active TB Disease M. tuberculosis in the body Yes Yes Tuberculin skin test reaction Positive Positive Symptoms No Yes Chest x-ray Normal Abnormal if pulmonary Sputum smears and cultures Negative *Positive Infectiousness Not Pulmonary TB is infectious A case of TB No Yes

Risk factors/ conditions for developing active TB I.Host immunity HIV infection(risk:20-40 time fold) Diabetes mellitus (risk: 3-5time fold) Malnutrition Extremes of Age (under-five and elderly) Prolonged steroid therapy Severe kidney disease Malignancies( Ex:leukemia , lymphoma…) Alcoholism

Cont, II. Conditions that damages the lung: Tobacco smoking Silicosis III. Intensity of exposure: Resident or workers in high-risk congregate settings Degree of infectiousness Household or other closed space contacts Time elapsed since exposure/infection: Infection within one year

Clinical Manifestation Pulmonary tuberculosis Persistent cough for 2 weeks or more Productive cough with or without blood-stained sputum Shortness of breath and chest pain Intermittent fevers, night sweats, loss of weight, loss of appetite, fatigue and malaise.

Extra-pulmonary TB Patients may present with non-specific symptoms such as unintentional weight loss , night sweats and fever for more than 2 weeks. other symptoms depend on the site or organ affected. The most common types of extra-pulmonary tuberculosis are

Cont, Tuberculous lymphadenitis : Caused by lymphatic spread of the organism, is one of the commonest forms of extra-pulmonary TB. Involvement of the lymph nodes is common in children and in person in the later stages of HIV infection.

Cont, Slowly developing painless cervical lymph node enlargement (regardless of HIV infection) is the commonest sites of involvement, though axillary and intra-abdominal lymph nodes may be affected.

Clinical presentations Overlying skin may breakdown Abscesses and chronic discharging sinuses which heal with scarring Tuberculous pleural effusion Is the commonest cause of a unilateral pleural effusion. It is also the commonest form of HIV-related extra- pulmonary disease.

Clinical features Presentation is most often acute with: Non-productive cough, Chest pain, shortness ofbreath and High temperature. Findings on clinical examination may include: Tracheal and mediastinal shift away from the side of the effusion Decreased chest movement Stony dullness on percussion on the side of the effusion.

TB of bones Localized pain and/or swelling, discharging of pus, muscle weakness, paralysis and stiffness of joints. can affect any bone but most commonly affects the vertebral column. Involvement of the thoracic vertebrae causes localized Back pain,deformity of the spine, and Angulated kyphosis ( gibbus ) Paravertebral tissue abscess

Intestinal TB Loss of weight and appetite Abdominal pain, diarrhea and constipation Mass in the abdomen Fluid in the abdominal cavity ( ascites )

Miliary Tuberculosis Presents with constitutional features rather than respiratory symptoms. Early symptoms are : Vague and lack specificity. Lassitude, anorexia, failure to thrive and Prolonged unexplained fever are common. TB meningitis is the commonest cause of death if miliary TB is untreated.

CNS TB( including TB meningitis) The patient may present with constitutional features and chronic meningitis and there is: Gradual onset and progression of headache and Decreased consciousness. It is most common in children between 6 month and 4 years of age.

Tuberculosis diagnostic methods Clinical manifestations Bacteriologic confirmation using Identification of the bacillus on ZN/FM microscopic examination( AFB) Identification of bacillary genetic material using molecular techniques like xpert MTB Culture media

Cont, Clinical decision of expert clinician by analyzing the supportive evidences from: Medical imaging of the affected organs eg . X-ray, Ultra sound,etc . Histo -pathologic studies of sample obtained from body tissue or fluid Biochemical analysis of body fluids: glucose, cell counts,& protein. Heamatology tests: Complete blood cell count, ESR

TB CASE DEFINITIONS Presumptive Tuberculosis: Refers to a patient who presents with symptoms or signs suggestive of TB, in particular cough of two weeks or more duration. Bacteriologically confirmed TB case: Refers to a patient from who has at least one Positive result either by smear microscopy, culture or Xpert MTB/RIF assay

Cont, Clinically diagnosed TB case: Refers to a patient who does not fulfill the criteria for bacteriological confirmation but has been diagnosed with active TB by a clinician and decided to treat with a full course of TB treatment. includes cases diagnosed on the basis of X-ray abnormalities or suggestive histopathology and Extra pulmonary TB cases diagnosed without laboratory identification of the mycobacterium.

Patient registration groups for drug susceptible TB Relapse patients : patients that have previously been treated for TB were declared cured or treatment completed at the end of their most recent course of treatment, and is now diagnosed with a recurrent episode of TB (either a true relapse or a re infection). Treatment after failure : patients are those who have previously been treated for TB and whose treatment failed (: smear positive results after fifth month during treatment) at the end of their most recent course of treatment.

Cont, New TB cases : refers to patients have never been treated for TB or have taken anti-TB drugs for less than 1 month. Previously treated TB case : refers to patients that have received 1 month or more of anti-TB drugs in the past.

Classifications based on drug resistance Mono-drug resistance : resistance to one first line anti-TB drug only. Poly-drug resistance : resistance to more than one first-line anti-TB drug (other than both Isoniazid and Rifampicin ). Multidrug resistance (MDR-TB): resistance to at least both Isoniazid and Rifampicin .

Cont, Extensive drug resistance (XDR-TB): resistance to any fluoroquinolone and to at least one of three second-line injectable drugs ( Capromycin , Kanamycin and Amikacin ), in addition to multidrug resistance (- Isoniazid and Rifampicin ).

Treatment Streptomycin (s) daily IM injection Ethambutol (E) Rifampin (R) Isoniazid (H) Pyrazinamide (Z)

Drug regimens (prescribed course of therapy) I.Short course chemotherapy regimen (DOTS) Intensive phase 2(RHZE) for two months Continuation phase 4(RH)for the next 4 months. II.Long course chemotherapy regimen. Intensive phase 2(RHZE) for 2 months Continuation phase 10 (RH)for the next 10 months

Treatment TB Patient type Standard Regimen TB types receiving the regimen Intensive phase Continuation phase Drug susceptible TB case 2(RHZE) 4(RH) All pulmonary TB cases Most Extrapulmonary TB cases 2(RHZE) 10 (RH) Extrapulmonary TB patients involving: CNS ( meningitis, tuberculoma ) vertebra and Osteoarticular space Drug Resistant TB( at least to rifampicin ) Second line anti-TB drugs Confirmed or clinically diagnosed DR-TB cases

Cont,

Nursing care Educate the patient how and when to take the prescribed medication. Tell the patient not to stop the medication unless he/she is told to do so. Tell the patient to come to the health institution if he/she develops drug side effects. Advice the patient on the importance of taking adequate and balanced diet and to eat what is available at home.

Prevention and control Chemotherapy of cases Chemoprophylaxis for contacts: INH ( Isoniazid ) for adults and children who have close contact with the source of infection Immunization of infants with BCG Educate patients with TB about the mode of disease transmission and how to dispose their sputum and cover their mouth while coughing,& sneezing.

Cont, Public health education about the modes of disease transmission and methods of control Improved standard of living Adequate nutrition Health housing Environmental sanitation Personal hygiene; etc. Active case finding and treatment

Leprosy (Hansen’s disease) A chronic bacterial disease of the skin, peripheral nerves and,in lepromatous patients, the upper airway. Infectious agent Mycobacterium leprae

Epidemiology Occurrence: Although common in rural tropics and subtropics, socio-economic conditions may be more important than climate itself. Endemic in south and southeast Asia,tropical Africa and Latin America. Reservoir - Humans

Mode of transmission Not clearly established. Householdand prolonged close contact appear to be important. Millions of bacilli are liberated daily in the nasal discharges of untreated lepromatous patients. Cutaneous ulcers in lepromatous patients may shed large number of bacilli. Organisms probably gain access (entrance) through the URT and possibly through broken skin. In children less than one year of age, transmission is presumed to be transplacental .

Cont, Incubation period- 9 months to 20 years. Period of communicability- Infectiousness is lost in most instances within 3months of continuous and regular treatment with dapsone or clofazamin or within 3 days of rifampicin treatment.

Cont, Susceptibility and resistance- The presence and form of leprosy depend on the ability to develop effective cell mediated immunity. Clinical Manifestation Clinical manifestations vary between two polar forms: lepromatous and tuberculoid leprosy.

Lepromatous ( Multibacillary form) Nodules, papules, macules and diffused infiltration are bilaterally symmetrical and usually numerous and extensive. Involvement of the nasal mucosa may lead to crusting,obstructed breathing and epistaxis . Occular involvement leads to iritis and keratitis .

Tuberculoid ( Paucibacillary form) Skin lesions are single or few, sharply demarcated, anesthetic or hyperesthetic and bilaterally symmetrical. Peripheral nerve involvement tends to be severe.

Cont, Borderline Has features of both polar forms and is more liableto shift toward the lepromatous form in untreated patients and toward the tuberculoid form in treated patients.

Diagnosis Complete skin examination (hyperesthesia, anesthesia, paralysis, muscle wasting or trophic ulcer which are signs of peripheral nerve involvement) with bilateral palpation of peripheral nerves ( ulnar nerve at the elbow, Peroneal nerve at head of fibula and the great auricular nerve) for enlargement and tenderness .

Cont, Skin lesion are tested for sensation (light touch, Pink prick, temperature discrimination). Demonstration of AFB in skin smears made by scraped incision method. Skin biopsy confined to the affected area should be sent to the experienced pathologists in leprosy diagnosis.

Treatment Dapsone three drugs for 12 months and then Refampicin dapsone alone for the next 12 months. Clfazamin Aspirin for mild reactions and inflammation Severe reaction can be treated with corticosteroids

Review Questions 1.What do you understand by air-borne disease transmission? 2.Which airborne disease occurrence should be reported immediately to the concerned health authorities for their prompt action? a. Pneumonia b. Tuberculosis c. Leprosy d. Meningococcal meningitis

Cont, 3.Select diseases which cause chronic illness: a. Tuberculosis b. Leprosy c. Measles d. Infection hepatitis 4.State some of the preventive and control methods for tuberculosis.

UNIT FOUR Manage a patient with arthropod borne disease 323 Zinabu D

Objectives At the end of this chapter, the student will be able to: Describe what arthropod borne disease means. Identify common vectors which transmit disease to man List the common vector-borne diseases. Participate in diagnosis and treatment of vector-borne diseases. Implement the common preventive and control methods of vector-borne diseases. 324 Zinabu D

Introduction Vector is any carrier of disease But in the case of the ‘vector-borne diseases’ it is Those invertebrate hosts ( insects or snails ), which are an essential part of the life cycle of the disease organism. A period of development of pathogen inside the vector is called the extrinsic incubation period 325 Zinabu D

Common vector borne disease includes Malaria Flariasis Endemic typhus Relapsing fever Schistosomiasis Guinea worm 326 Zinabu D

327 1. Malaria An acute infection of the blood caused by protozoa of the genus plasmodium inoculated into the human host by feeding female annoplin mosquito The most serious and life-threatening disease occurs from Plasmodium Falciparum infection. Zinabu D

Infectious agent Plasmodium falciparum /malignant tertian Invades all ages of red blood cells Red blood cell cycle is 48 hours Plasmodium Vivax /benign tertian Invades reticulocytes only& Red blood cell cycle is 48 hours Plasmodium ovale /tertian Invades reticulocytes only &Red blood cell cycle is 48 hours Plasmodium Malariae / Quartan malaria Invades reticulocytes only&Red blood cell cycle is 72 hours 328 Zinabu D

Epidemiology Endemic in tropical and sub-tropical countries of the world Affects 40% of the world population, Children less 5 years of age, pregnant women and travelers to endemic areas are risk groups Plasmodium falciparum 60% and Vivax 40% are common in Ethiopia 329 Zinabu D

Cont, Predisposing factors are: Environment- physical environment for the propagation, Patient source, Susceptible recipients Anopheles capable to transmit the parasite Socio-economic factors like immigration, war, poverty, ignorance, agricultural irrigation farms, etc. Reservoir - Humans 330 Zinabu D

Mode of transmission By the bite of an infective female anopheles mosquito Blood transfusion Hypodermic needles Organ transplantation and mother to fetus 331 Zinabu D

Cont, Incubation period- Varies with species Plasmodium falciparum 7-14 days Plasmodium virvax 8-14 days Plasmodium ovale 8-14 days Plasmodium Malariae 7-30 days 332 Zinabu D

Period of communicability Mosquitoes are infective as long as infective gametocytes are present in the blood of patients Once infected, mosquito remains infective for life Susceptibility and resistance Susceptibility is universal except in some host-resistance factors 333 Zinabu D

Non specific factors Increased splenic clearance reaction Hyperpyrexia- which is said to be schizontcidal Sickle cell traits are resistant to plasmodium falciparum Duffy blood group deficiency (Duffy antigen negative red blood cells) lack receptor for plasmodium vivax . Because of passive immunity infants are resistant in early life 334 Zinabu D

Cont, Specific factors This is a humoral and cell mediated immunity that is species and strain specific, and hard-won after repeated infection 335 Zinabu D

Life cycle . TRANSMISSION 1. Sporozoites inoculated when Anopheles mosquito takes a blood meal. HUMAN HOST 2. Sporozoite s infect liver cells. Multiplyby schizogony . Note: some sporozoites of P.vivax and p.ovale become dormant hypnozoites in liver. Become active after several months. 3. Liver schizonts rupture. Merozoite s enter red cells, become trophozites .Multiply by schizogony .* * with P. falciparum , schizogony occurs in capillaries of body organs. 4. Schizonts rupture. Merozoites infect new red cells. 5. Some merozoites develop into male and female gametocytes. MOSQUITO 6. gametocytes ingested by mosquito. 7. Male and female gametes fuse. Zygote oocyst in stomach wall. 8. Sporozoites form in oocyst . 9. Oocyst ruptures. Sporozoites reach salivary glands of mosquito 336 Zinabu D

Clinical feature: uncomplicated malaria Fever, Chills, Rigors, Sweating, Severe Headache, Generalized body and joint pain Nausea and or vomiting, Loss of appetite, Abdominal pain (especially in children) Irritability and refusal to feed (in infants), flu-like symptoms, fever above 38°C Splenomegaly, Pallor 337 Zinabu D

Complicated P. Falciparum malaria Inability to take in fluids (or breast milk in children), Repeated profuse vomiting, Haemoglobinuria(Dark or 'cola- coloured ' urine), Passing of very little urine Difficulty in breathing, Generalized weakness, inability to walk or sit without assistance Repeated generalized convulsions Altered consciousness, confusion, delirium, coma Tachypnea, respiratory distress and/or cyanosis 338 Zinabu D

Cont, Hypoglycemia Severe anaemia ( Hb < 6 g/ dL ) Hyperpyrexia (axillary temperature >38.5°C) Circulatory collapse or shock (cold limbs, weak rapid pulse) Spontaneous unexplained heavy bleeding (disseminated intravascular coagulation) 339 Zinabu D

Diagnosis Clinical manifestation and epidemiological grounds Blood film for hemoparasite(thin & thick) Rapid diagnostic tests (RDT)-if microscopy is unavailable 340 Zinabu D

Treatment of malaria 341 Zinabu D

Objectives of treatment Treat the patient and restore quality of life and productivity Prevent uncomplicated malaria from progressing to severe and fatal illness Prevent death from malaria complication Prevent the development and transmission of medicine resistance Decrease malaria transmission to others 342 Zinabu D

Treatment of uncomplicated P. Falciparum malaria First line Artemether + Lumefantrine, 20mg + 120mg in a fixed dose combination Alternative Quinine dihydrochloride, 10mg quinine sulphate salt/kg TID for 7 days 343 Zinabu D

Dose regimens of artemether-lumfantrine Weight (KG) AGE DOSE 5-14KG From 4 months to 2 years 1 tablet bid for 3 days 15-24KG From 3 years to 7 years 2 tablets bid for 3 days 25-34KG From 8 years to 10 years 3 tablets bid for 3 days >34KG 10 years & above 4 tablets bid for 3 days 344 Zinabu D

Treatment of uncomplicated P. Vivax malaria First line Chloroquine phosphate, 1 g, then 500mg in 6 hours followed by 500mg P.O., QD for 2 days Followed by Primaquine, 15mg base P.O., QID for 14 days. Alternatives Artemether + Lumefantrine , 20mg + 120mg in a fixed dose combination OR Quinine dihydrochloride , 10mg quinine sulphate salt/kg TID for 7 days 345 Zinabu D

Treatment of Severe and complicated P. falciparum malaria First line Artesunate , 2.4mg/Kg IV or IM given on admission (time = 0), then repeat at 12 hours, and 24 hours, then once a day for up to 5 days. Alternatives Artemether , IM 3.2mg/kg loading dose on the first day followed by 1.6mg/kg daily for five days 346 Zinabu D

Treatment of Severe and complicated P. falciparum malaria Quinine dihydrochloride: Loading dose : 20mg/kg in 500ml of isotonic saline or 5% dextrose over 4 hours (4ml/minute). The pediatric dose is the same but the fluid 10ml/kg replacement must be based on body weight. 347 Zinabu D

Cont, Maintenance dose : should be given 8 hours after the loading dose at a dose of 10mg /kg and it should be given 8 hourly diluted in 500 ml of isotonic saline or 5% dextrose over 4 hours 348 Zinabu D

Prevention and control Chemoprophylaxis Those who traveling to endemic areas Under-five children and pregnant mothers Vector control Avoiding mosquito breeding sites Chemicals Personal protection against mosquito bite (use of bed nets, etc.) 349 Zinabu D

2.Filariasis A disease caused by the reaction of the body to the presence of worms in the lymphatic system It results from infection with vector borne tissue-dwelling worm called filarae. 350 Zinabu D

Infectious agent : Three species of lymphatic dwelling filarial worms: Wucheriria bancrofti (vectors are culex , Anopheles and Aedes species) Brugia malayi (vector is mansonia species) Brugia timori (vector is Anopheles) Causes lymphatic Flariasis in humans 351 Zinabu D

Epidemiology Widely prevalent in tropical and subtropical areas of Africa, Asia, Pacific Region, Central and South America Found in Gambella region (western Ethiopia) Particularly endemic in areas of hot and humid climate. It is estimated that at least 128 million people are infected globally. 352 Zinabu D

Reservoir Humans are definitive hosts. Mode of transmission By bite of mosquito harboring infective larvae 353 Zinabu D

Life cycle . TRANSMISSION 1. Infective larvae penetrate skin when a mosquito takes a blood meal. HUMAN HOST* 2. Larvae become adult worms in the lymphatics . 3. Females produce sheathed Microfilariae which pass in to blood.* Animal hosts may be important for B. Malayi . MOSQUITO 4. Microfilariae ingested by mosquito. 5. Microfilariae lose sheath.Develop into infective larvae in thoracic muscles. 6. Infective larvae (sheathed) migrate to mouth parts. 354 Zinabu D

Incubation period One month, while allergic inflammatory manifestations may appear. 355 Zinabu D

Period of communicability- Humans may infect mosquitoes when microfilariae are present in the peripheral blood Microfilaremia may persists for 5-10 years or longer The mosquito becomes infective about 12-14 days after an infective blood meal Susceptibility and resistance Universal. Susceptibility to infection is probable 356 Zinabu D

Clinical Manifestation The presence of worms in the lymph vessels gives rise to a foreign-body reaction After the death of the worm, more proteins are released; the reaction then is even more severe 357 Zinabu D

Cont, Three phases may be distinguished Acute phase: Starts within a few months after infection Lymphadenopathy and Fever Eosinophilia Microfilariae are not demonstrable in the peripheral blood because the worms are not yet mature The acute phase is mainly due to a hypersensitivity reaction 358 Zinabu D

Subacute phase: This occurs after about one year following acute phases Worms are matured and microfilariae are present in the peripheral blood Reactions to the adult worms cause attacks of fever with lymphangitis, funiculitis or Epididymitis Recurrent attacks will sooner or later lead to hydrocele Lesions caused by microfilariae are less common and are associated with hyper eosinophilia and lung symptoms (tropical pulmonary eosinophilia syndrome). 359 Zinabu D

Chronic phase: After many years of repeated attacks, lymph glands and lymph vessels become obstructed ; as a result lymph edema develops Lymph edema most commonly seen in the leg s or scrotum (elephantiasis) but may also be present in vulva, breasts, or arms Since the adult worms have usually died, microfilariae are not seen in the blood 360 Zinabu D

Filariasis … 361 Zinabu D

Scrotum 362 Zinabu D

Cont Gross scrotal enlargement or wheelbarrow scrotum 363 Zinabu D

Penis 364 Zinabu D

Leg 365 Zinabu D

Arm 366 Zinabu D

Breast 367 Zinabu D

N:B Studies showed that elephantiasis of the lower legs is not encountered in Ethiopia. But there is elephantiasis of the foot called the big foot disease (elephantiasis of lower leg) as a result of accumulation of silica and other minerals in the leg (lymphatics) mostly occurring in bare-footed individuals. This big foot disease is named podoconiosis , which is common in the eastern high lands of Ethiopia ( Wolayita , Gojjam , Gondar, Gedeo , Sidamo , etc.) 368 Zinabu D

369 Diagnosis Clinical and epidemiological grounds Obstructive signs with history and travel to and residence in endemic areas Best established by identifying microfilariae in the peripheral blood (blood film) Mazoti test ( by adminstering Single dose of Diethylcarbamazin Citrate (DEC) causes the sequestered microfilaria to emerge to blood 45-60 minutes later. Zinabu D

Cont. Before taking blood sample one should know the periodicity of microfilariae that is, microfilariae appear in the peripheral blood during the night (nocturnal) in most parts of the world and during day (diurnal) in the South Pacific region 370 Zinabu D

Treatment Diethyl carbamazin Citrate (DEC) results in rapid disappearance of most microfilariae from blood but may not destroy the adult worm. Because of this, we need to repeat DEC annually for some years. Refer the patient for surgical treatment of hydrocele 371 Zinabu D

Prevention and control Reducing the vector population Mass and selective treatment Personal protection against mosquito bite. 372 Zinabu D

3.Schistosomiasis It is a blood fluke (trematode) infection with adult worms living within mesenteric or vesicle veins of the host over a life span of many years. Infectious agent Schistosoma mansoni Schistosoma Japonicum Schistosoma Hematobium Most prevalent species in Africa are S. mansoni and S. hematobium . 373 Zinabu D

Epidemiology S. mansoni is found in South America, Caribbean Islands, Africa and the Middle East S. hematobium is found in Africa and the Middle East. S. Japonicum is found in the far East The disease occurs worldwide and 2 million people are expected to be infected; however, most infected individuals show few or no signs and symptoms, and only a small minority develop significant disease 374 Zinabu D

Reservoir The principal reservoir for S. mansoni, and S. haematobium is man Other animals, like dog, cat, pig, cattle, water buffalo, horse and wild rodents, are hosts for S. japonicum Mode of transmission Infection is acquired from water containing free-swimming larval forms ( cercariae ) that have developed in snails 375 Zinabu D

Incubation period Acute systemic manifestations (katayama fever) may occur in primary infections 2-6 weeks after exposure, immediately before and during initial egg deposition The infection in humans can persist up to 10 years Snails release cercariae as long as they live (from several weeks to 3 months). Susceptibility and resistance Susceptibility is universal. Resistance is poorly defined. 376 Zinabu D

Life cycle . Zinabu D 377 TRANSMISSION 1. Cercariae penetrate skin when person in contact with contaminated water HUMAN HOST* 2. Cercariae I Schistosomula.Migrate through lungs and liver. 3. Become mature flukes inportal venous system. Flukes pair. 4. Migrate to veins of lower large intestine (S. haematobium to veins of bladder) 5. Eggs laid in venules . Burrow through into intestine (eggs of S. haematobium into bladder) 6. Eggs passed in feces. ( S.haematobium in urine). *S. japonicum also infects animals. FRESH WATER 7. Eggs reach water. Miracidia hatch Snail host 8. Miracidia penetrate snail. Become sporocysts and multiply (2 generations). Sporocysts Î cercariae . 9. Cercariae leave snail. ( S.Japonicum attaches to water vegetation).

Zinabu D 378

Clinical Manifestation The stages of schistosomiasis are: Invasion Maturation Established infection and Late stage 379 Zinabu D

Cont, I . Invasion stage Cercariae penetrate skin Cercarial dermatitis with itching papules and local edema Cercariae remain in skin for 5 days before they enter the lymphatic system and reach the liver. 380 Zinabu D

II.Maturation Schistosoma mature in the liver. Fever, eosinophilia, abdominal pain and transient generalized urticaria (known as katayama syndrome) Worms descend the portal vein. S. manson; migrates to mesenteric veins in the intestinal wall and S. haematobium to bladder plexus. This stage may be diagnosed as clinical malaria or may pass unnoticed. 381 Zinabu D

III.Established infection This is a stage of egg production and eggs reach to the lumen of bladder and bowel. Some eggs penetrate the tissue, reach the bladder and intestinal wall are discharged with urine and feces. Eggs that could not penetrate the tissue are carried with blood to the liver and lungs. 382 Zinabu D

Cont, Other eggs that fail to reach the lumen of the bladder or bowel provoke an inflammatory reaction. The inflammatory reaction, resulting in fibrosis, causes signs and symptoms of schistosomiasis. Sign of colitis with bloody diarrhea and cramps in S. mansoni infection. Terminal hematuria and dysuria in S. haematobium infection. 383 Zinabu D

IV.Late stage This is the stage of fibrosis, which occurs where there are eggs in the tissues. Around the bladder this may result in: Stricture of urethra leading to urine retention or fistula. Dilatation of ureters (hydroureter) and kidney (hydronephrosis) possibly leading to kidney failure Calcification of bladder. 384 Zinabu D

Cont, In the liver portal hypertension leads to hypersplenism and anemia, eosophageal varices and bleeding. In the lungs fibrosis results in pulmonary hypertension, which leads to congestive cardiac failure 385 Zinabu D

Diagnosis Demonstration of ova in urine or feces, Biopsy of urine and feces are repeatedly negative (rectal snip, liver biopsy, bladder biopsy). Treatment Praziquantel and oxamniquine are the drugs of choice but in Africa praziquantel is best because of resistance strain of oxamniquine. 386 Zinabu D

Prevention and control Treatment of cases Intermittent irrigation Drainage of water bodies Clearing of vegetation in water bodies to deprive snails of food and resting place Flooding Straightening and deepening margins of water bodies Educating the public about the mode of transmission and ways of prevention Proper disposal of human feces and urine Avoid swimming in water bodies known to have the infection Use rubber boots to prevent exposure to contaminated water. 387 Zinabu D

388 4.Guinea Worm Infection An infection of the subcutaneous and deeper tissues by large nematode. Infections agent Dracunculus medinensis, a nematode Reservoir - Humans Zinabu D

Cont, Zinabu D 389

Epidemiology In Africa (16 countries south of the Sahara) and in Asia (India and Yemen) especially in regions with dry climates Local prevalence varies greatly In some locales, nearly all inhabitants are infected, in others, few, mainly young adults 390 Zinabu D

Mode of transmission Larvae discharged by the female worm into stagnant fresh water are ingested by minute crustacean copepods, Cyclops or water fleas In about 2 weeks the larvae develop into the infective stage People swallow the infected copepods in drinking water from infested step wells and ponds. 391 Zinabu D

Cont, The larvae are liberated in the stomach, cross the duodenal wall, migrate through the viscera and become adults. The female, after mating, grows and develops to full maturity, then migrates to the subcutaneous tissues (most frequently of the legs). 392 Zinabu D

Cont. Incubation period- About 12 months Period of communicability From rupture of vesicle until larvae have been completely evacuated from the uterus of the gravid worm, usually 2-3 weeks In water, the larvae are infective for the copepods for about 5 days After ingestion by copepods, the larvae become infective for people after 12-14 days at temperatures >25 o c and remain infective in the copepods for about 3 weeks. 393 Zinabu D

Cont, Susceptibility and resistance Susceptibility is universal. No acquired immunity; multiple and repeated infections may occur in the same person 394 Zinabu D

Clinical Manifestation Few or no clinical manifestations are evident until just before the blister forms . Fever and generalized allergic symptoms, including periorbital edema, wheezing, and urticaria. The emergence of the worm is associated with local pain and swelling. When the blister ruptures, the adult worm releases larva-rich fluid and this is associated with a relief of symptoms. The shallow ulcer surrounding the emerging adult worm heals over weeks to months. Diagnosis Based on clinical and epidemiological grounds 395 Zinabu D

Treatment Gradual extraction of the worm by winding of a few centimeters on a stick each day remains the common and effective practice. Worms may be excised surgically. Administration of thiabendazole and mebedadazol may relive symptoms but has no proven activity against the worm 396 Zinabu D

Prevention and control Provide health education programs in endemic communities to covey three messages: The guinea-worm infection comes from their drinking water Villagers with blisters or ulcers should not enter any source of drinking water and That drinking water should be filtered through fine mesh cloth to remove copepods II. Provision of safe drinking water 397 Zinabu D

5.Endemic Typhus (Flea-borne typhus) A rickettsial disease whose course resembles that of louse borne typhus, but is milder Infectious agent: Rickettsia typhi (Rickettsia mooseri) 398 Zinabu D

Epidemiology Worldwide, found in areas where people and rats occupy the same buildings and where large numbers of mice live. Occurs sporadically. Reservoir: Rats, mice and possibly other small animals. Infection is maintained in nature by a rat-flea-rat cycle where rats are reservoirs 399 Zinabu D

Mode of Transmission- Infective rat fleas defecate rickettsia while sucking blood, contaminating the bite site and other fresh skin wounds. An occasional case may follow inhalation of dried infective flea feces. 400 Zinabu D

Pathogenesis Rickettsia is intracellular, gram- ve organism parasitize intestinal of arthropods Rickettsia from the blood of a human case are ingested by a biting louse and multiply in the gut of the insect Its faces are heavily infected Scratching of subsequent bite inoculate the organism It can also enter the body through rubbing the conjunctiva membrane Infected lice may die from the disease It can transmit the rickettsia to other lice through ingestion of faces Zinabu D 401

Cont, Trans ovarian (vertical transmission) doesn’t occur Infection is usually conveyed to human beings through the skin from the excreta of arthropods The organism multiply in capillary endothelial cells It produce lesion of the skin, central nervous system, heart, lung, kidney and skeletal muscles Endothelial proliferation associated to perivsular reaction It cause thrembosis and small haemorrhage Brain and cardiovascular systems are the affected areas. Zinabu D 402

Cont, Incubation period- From 1 to 2 weeks; commonly 12 days Zinabu D 403

Period of communicability Not directly transmitted from person to person. Once infected, fleas remain so for life. Susceptibility and resistance Susceptibility is general. One attack confers immunity. 404 Zinabu D

405 Clinical Manifestation Prodromal symptoms of headache, myalgia, arthralgia, nausea, and malaise developing 1 to 3 days before the abrupt onset of chills and fever Nearly all patients experience nausea and vomiting early in the illness The duration of untreated illness averages 12 days. Rash is present in only 13% of patients Pulmonary involvement: non-productive cough and pneumonia Zinabu D

Complication Delirium Epistaxis Constipation and paralytic ileus may occur In up to 50% of sever cases meningoencephalitis with meningism , tinnitus followed by deafness, dysphrgia Other problems include broachopneumonia supportive parotitis or Otitis media, peripheral blood vessel occlusion resulting in leg vein thrombosis Myocarditis Hypotension Cariac failure Zinabu D 406

Differential Diagnosis Typhoid Fever Measles Viral haemorrhgic fever Meningococcal septicaemia Zinabu D 407

Diagnosis Epidemiological ground Weil-Felix test OX-19 and OX-2 strain antibody Treatment Doxycyclin or Chloramphenicol Prevention and control Destroy rats from burrows and harborages. Use insecticides to abolish flea from living quarters. Treatment of patients . 408 Zinabu D

6.Relapsing Fever An acute infectious bacterial disease characterized by alternating febrile periods (recurrent pyrexial attacks) Infectious agent Borrelia recurrentis- cause of louse-borne relapsing fever Borrelia duttoni-cause of tick-borne relapsing fever 409 Zinabu D

Epidemiology Occurs in Asia, eastern Africa (Ethiopia and Sudan), the highland areas of central Africa and South America It occurs in epidemic form when it is spread by lice and in endemic form when spread by ticks 410 Zinabu D

Reservoir Humans for Borrelia recurrentis Wild rodents and soft ticks through trans ovarian transmission for tick borne relapsing fever Mode of transmission vector-borne:- Acquired by crushing an infected louse so that it contaminates the bite wound or an abrasion of the skin. 411 Zinabu D

Incubation period- 5-10 days usually 8 days. Period of communicability- Louse becomes infective 4-5 days after ingestion of blood from an infected person and remains so for life (20-40 days) 412 Zinabu D

Cont, Susceptibility and resistance Susceptibility is general. Duration and degree of immunity after clinical attack are unknown; repeated infection may occur . 413 Zinabu D

Clinical Manifestation Sudden onset of illness with chills, fever and prostration, headache, mayalgia and arthralgia There may be nausea and vomiting, jaundice and liver swelling After 4-5 days the temperature comes down, the patient stays free for 8-12 days and then a relapse follows with the same signs but less intense In untreated cases there may be up to ten relapses 414 Zinabu D

Diagnosis Clinical and epidemiological grounds Giemsa or Wright stain (blood film) Dark field microscopy of fresh blood. Treatment Admit the patient. Open vein before administering penicillin. Administer 400,000-600,000 IU procaine penicillin IM stat Tetracycline during discharge for 3 days Chloramphenicol in infants and children can be used in place of tetracycline. 415 Zinabu D

Nursing care Maintain body temperature to normal. Close vital sign monitoring for 3 hours after medication. Check whether there is reaction or not and report. Comfort the patient by providing antipain. Shaving of hair, and delousing of clothes. Prevention and control Control of vectors (louse) Personal hygiene Health education about hygiene and modes of disease transmission Delousing of patient’s clothes and his/her family Chemotherapy of cases and Chemoprophylaxis for contacts. 416 Zinabu D

. Thank you !!! Zinabu D 417

5/1/2024 418 UNIT FIVE SEXUALLY TRANSMITTED INFECTIONS(STIS) By Zinabu Dawit ( PBsc )

Objectives 5/1/2024 419 At the end of this session the students will able to:- Define STIs and Syndromic approach to manage STI Recognize causative agents Describe the epidemiology of STIs and risk factors. Explain mode of transmission Describe Clinical manifestation & incubation period Discuss the ways & principles of prevention & control . BY Zinabu Dawit(PBsc)

DEFINITION 5/1/2024 420 It is an infection passed from person to person through sexual contact(most common). Mother- to- child During pregnancy (HIV, syphilis) At delivery( Gonorrhea,chlamydia , genital herpes and HIV) Through breast feeding(HIV) Unsafe injections/contact with blood products(syphilis, HIV and hepatitis) BY Zinabu Dawit(PBsc)

Epidemiology 5/1/2024 421 According to WHO globally as many as 340 million new cases of curable STI occur each year with the largest proportion in the regions of south & south east Asia followed by the sub-Saharan African countries and Latin American & Caribbean countries(WHO,2001). There is little information on the incidence and prevalence of STIs in Ethiopia, except for adult prevalence of HIV(3.5%) and syphilis(2.7%) (MOH,2006) BY Zinabu Dawit(PBsc)

Cont.. 5/1/2024 422 There are a number of factors that increases the risk of transmission of STIs, including biological, behavioral and socio-cultural factors. Prevalence tends to be higher in urban than rural. STI occur most frequently among females between the 14-19,where as after the age of 19 it is slightly more frequent among males. BY Zinabu Dawit(PBsc)

Infectious agents 5/1/2024 423 STIs are a major public health problem in all countries, but are especially so in developing countries. More than 30 bacterial, fungal, viral, protozoal ( trichomonias vaginalis )and parasitic( pubic lice) pathogens are transmitted sexually. BY Zinabu Dawit(PBsc)

1.Bacterial infection 5/1/2024 424 BY Zinabu Dawit(PBsc)

2.Viral infections 5/1/2024 425 BY Zinabu Dawit(PBsc)

Viral infections… 5/1/2024 426 CMV (Human Cytomegalovirus):- saliva, venereal fluids, blood, organ transplant, urine, pregnancy, childbirth, breast milk Hepatitis B virus:-saliva, venereal fluids. (Note: Hepatitis A and Hepatitis E are transmitted via the fecal-oral route, Hepatitis C is rarely sexually transmittable. Herpes simplex virus( type I&II) skin and mucosal, transmissible with or without visible blisters. BY Zinabu Dawit(PBsc)

5/1/2024 427 Cont, 3. Fungal Candidiasis (yeast infection) 4. Parasites Crab louse or "pubic lice" Scabies ( Sarcoptes scabiei ) 5. Protozoal Trichomoniasis ( Trichomonas vaginalis)

Other causes 5/1/2024 428 BY Zinabu Dawit(PBsc)

Mode of transmission 5/1/2024 429 Person to person through sexual contact and mucosal contact Factors affecting the transmission 1.Biological (age, sex& immune status) Age:- Young(immature and cervical ectopy ) and sexually active post menopausal women(atrophy and loss of elasticity of the vagina ) are vulnerable. BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 430 Sex:- Infective agents enter the body most easily through a mucosal surface such as the lining of the vagina, so a women are more infected than men. Immune status:- Certain STIs increase the risk of transmission of HIV. HIV in turn facilitates the transmission of STIs and worsens the complications BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 431 2. Behavioral factors Changing sexual partner more frequently Having more than one sexual partner Having sex with casual partners, commercial sex workers or their clients. Use of alcohol or other drugs before or during sex. BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 432 3. Socio-cultural factors Little decision making power of women over sexual practices and choices Women tend to economically dependent on their male partners and are therefore more likely to tolerate men’s risky behavior. Sexual violence tends to be directed more towards women by men. BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 433 Early marriage to an adult male Permissive attitude is taken towards men allowing them to have more than one sexual partner. Harmful traditional practices (skin-piercing, circumcision using shared items). BY Zinabu Dawit(PBsc)

Incubation period 5/1/2024 434 It differs with the specific causative agent Syphilis : 10 days - 12 wks( usually 3 wks ) Chancroid : 3-14 days Gonorrhoea : 2 -7 days Chlamydia: 7 -14 days LGV:3-30 days Herpes genitalia:2 – 12 days Candidiasi s :variable. Trichomoniasis :4 - 20 days, average 7days BY Zinabu Dawit(PBsc)

Approaches to STIs management 5/1/2024 435 Classical Approach Etiological approach Clinical approach Etiological approach : uses laboratory tests to identify the causative agent. Clinical approach : uses clinical experience to identify symptoms which are typical for a specific STI. BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 436 Advantages of etiologic approach Patient satisfaction Asymptomatic screening Important for syphilis case-finding in pregnant. BY Zinabu Dawit(PBsc)

Disadvantage of Etiological approach 5/1/2024 437 Requires skilled personnel and sophisticated equipment Laboratory tests for diagnosis are expensive(E.g. chlamydia trachomatis)and time-consuming. Treatment does not begin until the results are obtained. Testing facilities are not available at the primary health care level. BY Zinabu Dawit(PBsc)

Disadvantage of clinical approach 5/1/2024 438 Only accurate for 50% of STI cases. Mixed infections are common and the clinician may diagnosis only one of them. Different STIs cause similar symptoms, so clinician may pick the wrong to treat Miss-treated or untreated infections can lead to complications and continued transmission. BY Zinabu Dawit(PBsc)

2. Syndrome approach 5/1/2024 439 Syndrome is a group of symptoms that patients describe, combined with classic signs the providers observe during physical examination.. A number of different organisms that causes STIs give rise to limited number of syndrome. Giving treatment targeting all the locally known pathogens which can cause the syndrome. BY Zinabu Dawit(PBsc)

5/1/2024 440 Cont, Developed by WHO Does not require laboratory tests Tested in many countries since 1970’s STIs grouped into 7 main categories, according to symptoms and signs BY Zinabu Dawit(PBsc)

Principles of syndrome management 5/1/2024 441 Recognize the syndrome The syndrome could be caused by one or more of a number of organisms Treat with a combination of drugs Drugs should cover the common organisms potentially responsible for the syndrome Organisms must be sensitive to the drugs BY Zinabu Dawit(PBsc)

The four steps in syndrome STIs management 5/1/2024 442 History taking and physical examination Syndrome diagnosis and treatment, using flow charts Education and counseling on HIV testing and safer sex, including condom promotion and provision. Management of sexual partner. BY Zinabu Dawit(PBsc)

Advantage of syndrome approach 5/1/2024 443 Treatment covers the most common organisms potentially responsible for the syndrome Simple, rapid and inexpensive Complete care offered at first visit Patients are treated for possible mixed infections BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 444 Can be used at all levels of the health system Accessible to a broad range of health workers Promotes standardization Avoids unnecessary referrals to hospitals Does not require laboratory tests BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 445 Disadvantages Asymptomatic infections are missed Overuse of drugs(Over-treatment): costs, side effects, resistance Lack of acceptance by clinicians BY Zinabu Dawit(PBsc)

Common STI Syndromes 5/1/2024 446 Urethral discharge Abnormal Vaginal discharge Genital ulcer Lower abdominal pain Scrotal swelling Inguinal bubo Neonatal Conjunctivitis BY Zinabu Dawit(PBsc)

SIGNS AND SYMPTOMS OF THE MAIN STIs SYNDROMES AND THEIR CAUESES SYNDROME SYMPTOMS SIGN MOST COMMON CAUSES Vaginal discharge Unusual vaginal discharge vaginal itching Dysuria Dyspareunia Abnormal vaginal discharge Vaginitis Trichomoniasis , candidiasis Bacterial vaginosis Gerdenella vaginalis Cervicitis Gonorrhea Chlamydia 2. Urethral discharge Urethral discharge Dysuria Frequent urination Urethral discharge (if necessary ask patient to milk urethra) Gonorrhea chlamydia 3. Genital ulcer Genital sore Genital ulcer Syphilis Chancroid Genital herpes 5/1/2024 447 BY Zinabu Dawit(PBsc)

Cont.. 5/1/2024 448 4.Lower abdominal pain Lower abdominal pain Dyspareunia Vaginal discharge Lower abdominal tenderness on palpation Temperature>38 c Gonorrhea Chlamydia Mixed anaerobes 5. Scrotal swelling Scrotal pain and swelling Scrotal swelling Gonorrhea Chlamydia 6. I nguinal bubo Painful enlarged inguinal lymph nodes Enlarged inguinal lymph nodes Fluctuation Abscess or fistulae LGV chancriod 7. Neonatal conjunctivitis Swollen eyelids Discharge Baby cannot open eyes Oedema of the eyelids Purulent discharge Gonorrhea Chlamydia BY Zinabu Dawit(PBsc)

GENITAL ULCER 5/1/2024 449 The common ulcerative lesions of the genitalia in men and women are:- Primary syphilis( T.pallidum ) ( Hard chancre) Genital herpes(HSV-2) Chancroid (Haemophilus ducreyi ) (soft chancre) Lymphogranuloma venereum (LGV)( chlamydia trachomatis serovars L1,L2 or L3. Granuloma inguinale also known as Donovanosis , caused by bacterium klebsiella granulomatis BY Zinabu Dawit(PBsc)

Genital ulcer 5/1/2024 450 BY Zinabu Dawit(PBsc)

Genital warts, HPV infection, cervical cancer 5/1/2024 451 BY Zinabu Dawit(PBsc)

Genital Ulcer Syndrome 5/1/2024 452

Genital Ulcer Disease Treatment 5/1/2024 453 Recommended treatment for non-vesicular genital ulcer Benzanthine penicilline 2.4 million units IM stat or Doxycycline 100 mg bid for 15 days plus Ciprofloxacin 500mg, po , bid for 3 days or Erythromycin 500 mg, po , QID for 7 days Recommended treatment for vesicular or recurrent genital ulcer Acyclovir 200 mg five times per day for 5 days, or Acyclovir 400 mg TID for 5 days BY Zinabu Dawit(PBsc)

Cont 5/1/2024 454 Recommended treatment for vesicular, multiple first episode genital ulcer. Acyclovir 400mgTID for 10 days/ 200mg five times per day for 10 days. Alternatives For syphilis For chancroid For LVG Procain penicillin Ceftriaxone Tetracycline Benzylpencillin Tetracycline BY Zinabu Dawit(PBsc)

Urethral discharge 5/1/2024 455 N. gonorrhea and C. trachomatis are generally the most common cause. Trichomonas vaginalis is the 2 nd most common cause in Ethiopia, exceeds C.trachomatis and is responsible for persistent or recurrent urethral discharge. Mycoplasma genitalium and ureaplama urealyticum rarely cause BY Zinabu Dawit(PBsc)

Cont… 5/1/2024 456 Sign and symptoms Large amount of purulent urethral discharge. Pruritis( burning sensation on urination) Dysuria Anal discharge and rectal bleeding ( proctatis ) BY Zinabu Dawit(PBsc)

Urethral discharge 5/1/2024 457 BY Zinabu Dawit(PBsc)

milking penis 5/1/2024 458 BY Zinabu Dawit(PBsc)

Urethral Discharge Syndrome 5/1/2024 459 BY Zinabu Dawit(PBsc)

complains of urethral discharge or dysuria Take history & Examine [ Milk urethra if necessary] Discharge present? Other STIs ? No Yes Use appropriate flow chart Yes Urethral discharge Educate on RR Offer CTP Promote & provide condoms Treat for CT Educate on risk reduction Offer HCT Promote & provide condoms Partner management Advise to return in 7 days if symptoms persist Figure 1 5/1/2024 460 BY Zinabu Dawit(PBsc)

Persistent or Recurrent Urethral Discharge in Men Take history and examine Does history confirm reinfection or poor compliance? Treat for trichomonas vaginalis Educate/counsel Promote and provide condoms Return in 7 days Improved Discharge confirmed Patient complains of persistent/ recurrent urethral discharge or dysuria Other STIs present Use appropriate flow chart Repeat urethral discharge treatment Refer Educate/counsel Promote and provide condoms Offer VCT Yes No No Yes Yes Educate/counsel Promote and provide condoms Offer VCT No Yes No 5/1/2024 461 BY Zinabu Dawit(PBsc)

Recommended Treatment for Urethral Discharge and Burning on Urination 5/1/2024 Ciprofloxacin 500 mg po stat, or Spectinomycin 2g IM stat Plus Doxycycline 100 mg po BID for 7 days, or Tetracycline 500 mg po QID for 7 days, or Erythromycin 500 mg po QID for 7 days BY Zinabu Dawit(PBsc)

Recommended treatment for persistent /recurrent urethral discharge 5/1/2024 463 Metronidazole 2mg single dose Plus Erythromycin base 500mg qid X7 days or Erythromycin ethylsuccinate 800mg qid x 7days. For infection with T. vaginalis Metronidazole 2mg PO stat , avoid alcohol while taking. BY Zinabu Dawit(PBsc)

Abnormal Vaginal Discharge 5/1/2024 464 Common causes: N. gonorrhea Chlamydia trachomatis sexually acquired Trichomonas vaginalis Gardnerella vaginalis Candida albicans endogenous infection BY Zinabu Dawit(PBsc)

Differences Between Vaginitis and Cervicitis 5/1/2024 465 Vaginitis Cervicitis Caused by trichomoniasis, Candidiasis and bacterial vaginosis Caused by gonorrhea and Chlamydia  Most common cause of vaginal discharge Less common cause of vaginal discharge Easy to diagnose Difficult to diagnose Treatment of partner not necessary Need to treat partner BY Zinabu Dawit(PBsc)

5/1/2024 467 Patient complains of vaginal discharge or vulval itching/ burning Abnormal discharge present Take history, examine patient (external speculum and bimanual) and assess risk Lower abdominal tenderness or cervical motion tenderness Was risk assessment positive? Is discharge from the cervix? Vulval edema/curd like discharge Erythema excoriation present Treat for bacterial vaginosis and trichomoniasis Treat for chlamydia, gonorrhea, bacterial vaginosis and trichomoniasis Use flow chart for lower abdominal pain Educate Counsel Promote and provide condoms Offer VCT Educate Counsel Promote and provide condoms Offer VCT Treat for candida albicans No Yes Yes Yes No No No Yes Vaginal Discharge BY Zinabu Dawit(PBsc)

Risk assessment: 5/1/2024 468 Multiple sexual partners Recent unprotected sex Age < 25 yrs New partner BY Zinabu Dawit(PBsc)

Recommended Treatment for Vaginal Discharge 469 Metronidazole 500mg PO BID for 7 days plus Clotrimazole vaginal tabs 200mg at bed time for 3 days Ciprofloxacin 500mg PO stat or Spectinomycin 2gm IM stat plus Doxycycline 100mg PO BID for 7 days plus Metronidazole 500mg BID for 10 days Risk Assessment Negative for STI Risk Assessment Positive for STI

Recommended regimens for pregnant women 5/1/2024 470 Metrondazole use in first trimester pregnancy is not recommended ,but lower dose or single dose rather than a long course use when early treatment has chance of preventing adverse pregnancy out comes. Metrondazole 2g po as single dose, if treatment is imperative during the first trimester. Metrondazole 200/250mg TIDx 7days after 1 st trimester BY Zinabu Dawit(PBsc)

Lower Abdominal Pain (PID) 5/1/2024 471 PID is ascending infection of the upper genital tract (cervix, uterus, tubes, ovaries or pelvic cavity) and is associated with polymicrobial organisms. The morbidity from PID causes a 7-10 fold increase in ectopic pregnancy, chronic pelvic pain and infertility(15-75%) BY Zinabu Dawit(PBsc)

PID… 5/1/2024 472 Common etiologies Sexually transmitted: Neisseria gonorrhea, Chlamydia trachomatis Mycoplasma hominis Others (non-STI): Streptococci E. coli H. influenza IUCD/endometrial biopsy BY Zinabu Dawit(PBsc)

Micro-organisms originating in the endocervix Ascend into the endometrium, fallopian tubes, and peritoneum causing PID ( endometritis , salpingitis , oophoritis , peritonitis ) 5/1/2024 473 BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 474 Signs and symptoms Lower abdominal pain and lower abdominal tenderness cervical motion tenderness Increased Vaginal discharge Pain during intercourse Painful urination Dysmenorrhea History of fever and chilis , nausea & vomiting BY Zinabu Dawit(PBsc)

Differential diagnosis 5/1/2024 475 Acute appendicitis Ectopic pregnancy Endometriosis Acute hemorrhage from an ovarian cyst Septic incomplete abortion Cholecystitis BY Zinabu Dawit(PBsc)

5/1/2024 476 Lower Abdominal Pain Patient complains of lower abdominal pain Take history including gynecological And examine (abdominal and vaginal) Any of the following present Missed overdue period Recent delivery/ abortion Miscarriage Abdominal guarding And/or rebound tenderness Abdominal mass Abnormal vaginal bleeding Refer the patient for surgical or gynecological opinion and assessment Before referral set up an IV line and resuscitate if required Is there cervical excitation tenderness Or lower abdominal tenderness And vaginal discharge Manage for PID Review in three days Continue treatment until completed Educate and counsel Offer VCT Promote and provide condom Ask patient to return if necessary Patient has improved Refer patient Manage appropriately Any other illness found Yes No Yes Yes No No Yes

Recommended Treatment for PID Out patient Inpatient Ciprofloxacin 500mg PO bid for 7 days, OR Spectinomycin 2gm IM stat plus Doxycycline 100mg BID for 14 days plus Metronidazole 500mg BID for 14 days Ceftriaxone 250mg IV BID, OR Spectinomycin 2gm IM BID plus Doxycycline 100mg BID for 14 days plus Metronidazole 500mg BID for 14 days, OR Chloramphenicol 500mg IV QID 477

Scrotal Swelling 5/1/2024 478 Common causes of scrotal swelling depends on age of patient. Age <35 yrs -Neisseria gonorrhea -Chlamydia trachomatis Age > 35yrs commonly caused by other organisms if the patient has not been involved in unsafe sex. -Mumps -Onchocerciasis -TB -Inguinal hernia -Testicular torsion BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 479 Pre-pubertal children - coliform - Pseudomonas - Mumps virus BY Zinabu Dawit(PBsc)

5/1/2024 480 Scrotal Swelling Patient complains of scrotal swelling or pain Take history, examine, offer HIV test Scrotal swelling or pain present? History of trauma or testis elevated or rotated? or Diagnosis in doubt? Refer patient to hospital Signs of other STI present? Reassure patient, educate, counsel, provide condoms. Review if symptoms persist Treat according to appropriate flowchart Treat for chlamydia and gonorrhea. Review in 7 days Patient has improved? Complete treatment course, reinforce education and counseling Review if symptoms persist Yes Yes No Yes No No Yes No

Scrotal Swelling Recommended Therapy 5/1/2024 481 Ciprofloxacin 500mg PO stat, or Spectinomycin 2gm IM stat plus Doxycycline 100mg PO BID for 7 days, or Tetracycline 500mg BID for 7 days BY Zinabu Dawit(PBsc)

Inguinal Bubo 5/1/2024 482 Painful, fluctuant Swelling of inguinal lymph nodes in groin. Common causes: Chlamydia trachomatis( serovar L1, L2 &L3) (LGV) Homophiles ducreyi ( chancroid ) Calymatobacterium granulomatis (granuloma inguinale ) T.pallidum (some times) BY Zinabu Dawit(PBsc)

Inguinal Bubo 5/1/2024 483 Courtesy of CDC/ Susan Lindsley BY Zinabu Dawit(PBsc)

Sign and symptoms 5/1/2024 484 Produces necrosis and abscess in the lymph nodes( except syphilis) Fluctuant bubo Enlarged lymph nodes usually painful Warm, tender and discharging pus on P/E BY Zinabu Dawit(PBsc)

5/1/2024 485 Inguinal Bubo Patient complaining of inguinal swelling Take history and examine Inguinal/femoral bubo present? Ulcers present Treat for LGV, GI and chancroid Aspirate if fluctuant Educate on treatment compliance Counsel on risk reduction Promote and provide condoms Partner management Offer VCT if available Advise to return in 07 days Refer if no improvement Any other STI present Use appropriate flow chart Educate Counsel Offer VCT Promote and provide condoms Use genital ulcer flow chart No No Yes Yes No BY Zinabu Dawit(PBsc)

Inguinal Bubo 5/1/2024 486 Recommended treatment: Ciprofloxacin 500mg PO BID for 3 days and Erythromycin 500mg PO QID for 14 to 21 days or Doxycycline 100 mg 14 days. BY Zinabu Dawit(PBsc)

Neonatal Conjunctivitis( Ophthalmia neonatorum ) 5/1/2024 487 Neonatal conjunctivitis is swelling (inflammation) or infection of the tissue lining the eyelids in a newborn, in a less than one month of age, as a result of genital infection of the mother, transmitted during birth. Causes: Neisseria gonorrhea(blindness may follow) Chlamydia trachomatis Gonorrhea accounts for 20 -75% and Chlamydia for 15- 35% of cases in developing countries. BY Zinabu Dawit(PBsc)

Symptoms 5/1/2024 488 Infected newborn infants develop drainage from the eyes within 1 day to 2 weeks after birth. The eyelids become puffy, red and tender. There may be watery, bloody or thick pus-like drainage from the infant's eyes. BY Zinabu Dawit(PBsc)

Ophthalmia neonatorum For babies older than one month the cause is unlikely to be an STIs. 5/1/2024 489 BY Zinabu Dawit(PBsc)

5/1/2024 490 Neonatal Conjunctivitis Neonate presents with eye discharge Take history and examine child Purulent conjunctivitis present? Complete treatment course, reinforce education and counseling Review if necessary Treat baby for gonococcal and chlamydial opthalmia AND Treat mother and partner for gonorrhoea and chlamydia Educate and counsel Review baby in 7 days or sooner if symptoms worsen Signs of other illness present? Treat appropriately Reassure mother, educate parents Review if symptoms persist Eye infection cleared? No No Yes Yes Review in 7 days Yes Refer for specialist opinion and management No BY Zinabu Dawit(PBsc)

Treatment 5/1/2024 491 Spectinomycin 25mg/kg IM stat max.dose 75mg. or ceftriaxone 50mg/kg max.dose 125mg IM stat plus Erythromycin 50mg/kg PO in 4 divided doses for 14 days May lead to blindness if not treated properly BY Zinabu Dawit(PBsc)

Prevention of Neonatal conjuctivitis 5/1/2024 492 As soon as the baby is born, carefully wipe both eyes with dry, clear cotton wool. Then apply 1% silver nitrate solution or 1% TTC eye ointment or 0.5%Erythromycin ointment or 2.5% povidone iodine solution. NB. The baby’s eyes are usually swollen after birth and may be difficult to open, so open the eyes and apply the eye ointment on the lower conjuctival and not on eyelids. BY Zinabu Dawit(PBsc)

Principles of prevention and control of STIs 5/1/2024 493 Reduction of the average rate of sexual exposure. Reduction of the efficiency of transmission. Shortening the duration of infectivity of STI(early detection & treatment). BY Zinabu Dawit(PBsc)

Prevention of STIs 5/1/2024 494 Primary prevention :- Aims to prevent people from being infected with STIs. Safer sexual behavior: ABC Non penetrative sex: masturbation Secondary prevention :- Promoting STI care-seeking behavior, through: -public education campaigns -providing non-stigmatizing and non- discriminatory health services BY Zinabu Dawit(PBsc)

5/1/2024 495 Providing quality STIs care Ensuring a continuous supply of highly effective drugs and condoms. Rapid and effective treatment of people with STI , through comprehensive case management of STIs w/c includes: Correct diagnosis Correct therapy BY Zinabu Dawit(PBsc)

Cont. 5/1/2024 496 Educate on the nature of infection, safer sexual behavior & risk reduction Educate on treatment compliance Demonstrate the correct use of condoms & provision of condoms Advise on partner treatment BY Zinabu Dawit(PBsc)

. 5/1/2024 497 Thank you!! BY Zinabu Dawit(PBsc)

HIV/ AIDS 5/1/2024 498 HIV:-human immune deficiency virus AIDS:-Acquired immunodeficiency syndrome was first reported by the US CDC in 1981GC. By 1984GC. HIV was identified as the causative agent for AIDS by Luc Montanier (Pasteur Institute, Paris) and Robert Gallo. HIV is an enveloped and special family of retroviruses, a class of RNA virus. BY Zinabu Dawit(PBsc)

HIV AND THE IMMUNE SYSTEM 5/1/2024 499 The WBC play an important role to defend the body against all kinds of diseases. The CD4 is a special type of lymphocyte(T-cells) with a marker on its surface called CD4. In order for the cell to be infected by HIV, there must be CD4 receptors which are occur on T- helper lymphocytes, monocytes and macrophages cell lines. BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 500 Although helper T cells seem to be the main target for HIV, other cells become infected as well( monocytes,macrophages ) HIV destroys CD4 cells and consequently the body is exposed to conditions called opportunistic infections( OI). These CD4 cells can be compared like army general/commander BY Zinabu Dawit(PBsc)

The immune system and HIV 5/1/2024 501 Immune system Innate immunity Fast/immediate Short-lived (E.G., Skin as a mechanical barrier, and the acid in the stomach) Humeral immunity (antibody-mediated) Adaptive immunity slow but progressive long-lived memory Cellular immunity (T-cell-mediated) BY Zinabu Dawit(PBsc)

VIRAL STRUCTURE 5/1/2024 502 The outer envelope includes two major glycoproteins, gp120 and gp41 The viral core has two copies of HIV RNA, core protien (P24), matrix protein( P17) & three enzymes(reverse transcriptase, integrase & protease ). BY Zinabu Dawit(PBsc)

5/1/2024 503 BY Zinabu Dawit(PBsc)

There are 8 major steps in the virus life cycle . 5/1/2024 504 HIV LIFE CYCLE BY Zinabu Dawit(PBsc)

Step 1: Binding/ Fusion 5/1/2024 505 The virus locks onto a special receptors on the surface of the cell The gp120 has specific affinity and binding of the viral gp120 leads to conformational changes of viral envelope Expose gp41 to initiate the fusion process . BY Zinabu Dawit(PBsc)

Step2: Penetration and uncoating 5/1/2024 506 Internalization to the cytoplasm of the host cell uncoating /releasing of the viral core proteins (proteins, RNA& enzymes) BY Zinabu Dawit(PBsc)

Step3: Reverse transcription 5/1/2024 507 The enzyme Reverse transcriptase makes a DNA copy of the viral RNA. The new DNA is called “ proviral DNA”. BY Zinabu Dawit(PBsc)

Step4: Integration 5/1/2024 508 The new DNA(HIV genes) enters the nucleus and becomes part of the cell’s DNA. The integrated viral DNA may persist in a latent state for some time or will be active. BY Zinabu Dawit(PBsc)

Step 5: Transcription 5/1/2024 509 Transcription of viral DNA to mRNA (instructions for making new HIV proteins, with the help of RNA polymerase). When the host cell tries to make new proteins , it will start producing new HIV proteins using the cell’s “ machinery”. BY Zinabu Dawit(PBsc)

Step 6: Translation 5/1/2024 510 The mRNA leaves to the cytoplasm and carries instructions for making new viral proteins. Structural proteins, regulatory proteins, accessory proteins & other genetic materials for the new virions . BY Zinabu Dawit(PBsc)

Step7: Viral assembly & maturation 5/1/2024 511 Protease process the new proteins into their functional forms Assemble together to form mature virion at the inner surface of the host cell membrane. Soon each copy of RNA(HIV genes) is packaged in a protective shell. BY Zinabu Dawit(PBsc)

Step8: Budding 5/1/2024 512 The virus acquires a lipid coat from the host cell Thousands of viruses break out of the cell & released as new viruses and go on to infect other cells. BY Zinabu Dawit(PBsc)

5/1/2024 513 BY Zinabu Dawit(PBsc)

Classification of HIV 5/1/2024 514 HIV-1 :- Was described in 1983 Responsible for the global pandemic. Three distinctive hiv-1 virus groups, m, o & n. HIV-2:- Was described in 1985 Limited to west africa Causes AIDS much more slowly than HIV-1 BY Zinabu Dawit(PBsc)

MODES OF TRANSMISSION OF HIV 5/1/2024 515 Sexual relations (anal, vaginal and oral sex). Transfusion with contaminated blood or blood products The use of needles, syringes and cutting or perforating objects contaminated by HIV infected blood Transmission from mother to child BY Zinabu Dawit(PBsc)

HIV IS NOT TRANSMITTED 5/1/2024 516 Body fluids like tears, saliva,sweat and urine Personal contacts: kisses on mouth , hugging, hand shakes Social contacts: During work, in the school , cinema, restaurant and sauna Air or water sneezing, coughing, swimming Contact with common items: pens, toilets, towels sheets, soap BY Zinabu Dawit(PBsc)

Spectrum of HIV tests 5/1/2024 517 HIV diagnosis(antibody/ antigen testing) Enzyme-linked immunosorbent assay(ELISA) Rapid tests Western blot Early diagnosis in infants DNA PCR Initiation and monitoring of ART CD4 count(start HAART if CD4 counts <200 cells/mm3). Viral load(start HAART if a viral load >100,000 copies/mL) BY Zinabu Dawit(PBsc)

THE CLINICAL COURSE OF HIV 5/1/2024 518 During the process of sero -conversion often patients develop non-specific flu- like symptoms. These symptoms include: Fever Fatigue Pharyngitis Lymphadenopathy Rash BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 519 Three types of progression are noted . 1. Typical progressors Account for 90% of individuals who can stay for 7 -10 years before developing symptoms. The viral set point is medium in this group 2. Rapid progressors Account for 5%, they develop AIDS with in 3 years -patients have high viral set point. BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 520 3. Long term non- progressors Account for <10%,have stable CD4 count for more than 10 -15 years This group has remarkably low viral set point. BY Zinabu Dawit(PBsc)

Patterns of HIV Disease Progression 5/1/2024 521 . HIV Infection Long-term Non-progressors Rapid Progressors Typical Progressors <3 years 7-10 years >10-15 yr Normal, Stable CD4 90 % <5 % <10 % BY Zinabu Dawit(PBsc)

OPPORTUNISTIC INFECTIONS(OIs) 5/1/2024 522 People with good immune systems have CD4 counts between 450 and 1500cells/mm 3. As CD4 level declines the risk of getting opportunistic infections increases. When the number of CD4 has decreased below 450cells/mm 3 , the person will start to have some opportunistic infections When the CD4 count has decreased below 200cells/mm 3 , the person will have very serious OIs. BY Zinabu Dawit(PBsc)

Overview of Aetiologies 5/1/2024 523 BY Zinabu Dawit(PBsc)

OI PROPHYLAXIS 5/1/2024 524 Cotrimoxazole prophylaxis is the most commonly used for:- Pneumocystis pneumonia Toxoplama brain abscess Isospro belli Non- typhodal salmonella species Pneumonia from s.Pneumonia P. Falciparum malaria BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 525 Indication WHO-clinical stage 2,3 & 4 in the absence of CD4 count WHO – clinical stage 3 & 4 irrespective of the level of CD4 count. Patients with CD4 count of ≤ 350/mm 3 People with TB and HIV co- infection. Dose: cotrimoxazole 480mg two tablets or 960 mg one tablet daily . BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 526 2 . Fluconazole prophylaxis (200mg/day) after full treatment of cryptococcal meningitis when on ART, stop when CD4 has been greater than 100 for 6 months after at least 6 months treatment. 3. INH prophylaxis prevention of TB which is common in patients with HIV. BY Zinabu Dawit(PBsc)

WHO CLINICAL STAGING 5/1/2024 527 Used for assessment at baseline or entry into HIV care Provide simple guidance to assist clinical care providers on when to start or substitute ART used to assess current clinical status of individuals in HIV care, either on or off ART BY Zinabu Dawit(PBsc)

Cont… 5/1/2024 528 Encourage clinical care providers to offer diagnostic testing for HIV Be used to guide clinicians in assessing the response to ART. New or recurrent OIs after ART may suggest an inadequate response to treatment Clinical events in the first three months after ART has begun may be caused by immune restoration syndrome (IRS) BY Zinabu Dawit(PBsc)

WHO clinical staging for HIV 5/1/2024 529 Primary HIV Infection Stage 1 - Asymptomatic Stage 2 - Mild disease Stage 3 - Moderate disease Stage 4 – Severe disease (AIDS) BY Zinabu Dawit(PBsc)

Primary HIV infection 5/1/2024 530 Asymptomatic Acute retroviral syndrome( non-specific symptoms) Fever Fatigue Pharyngitis Rash BY Zinabu Dawit(PBsc)

Clinical stage 1 5/1/2024 531 Asymptomatic Persistent generalized lymphadenopathy (PGL) PGL is swollen or enlarged lymph nodes > 1cm in 2 or more non-contiguous extra-inguinal sites in absence of known cause BY Zinabu Dawit(PBsc)

Clinical stage 2 5/1/2024 532 Moderate unexplained weight loss(<10%) Recurrent respiratory tract infections Herpes zoster Angular cheilitis BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 533 Recurrent oral ulcerations Papular pruritic eruptions Seborrhoeic dermatitis Fungal nail infections of fingers BY Zinabu Dawit(PBsc)

Papular Pruritic Eruption (PPE) 5/1/2024 534 Hyperpigmented papules and nodules (up to 1 cm) with severe itching. Often ulcerations and scars because of scratching Most frequently on extensor side of arms and legs BY Zinabu Dawit(PBsc)

PPE treatment 5/1/2024 535 Antihistamines Potent topical steroids Calamine lotion ART BY Zinabu Dawit(PBsc)

Impetigo 5/1/2024 536 Local antiseptics Cloxacilline 500 mg 4x/d for 10 days BY Zinabu Dawit(PBsc)

Scaly skin eruption on the border between face and hair and side of the nose, scalp or chest These are often greasy scales and redness. It also common in non-HIV. 5/1/2024 537 Seborrhoeic dermatitis BY Zinabu Dawit(PBsc)

Seborrhoeic Dermatitis 5/1/2024 538 Whitfields ointment bd OR Ketoconazole ointment bd OR Miconazole cream bd Local steroid cream added if severe and lots of inflammation BY Zinabu Dawit(PBsc)

Tinea Pedis 5/1/2024 539 Interdigital itching, scaling, fissures and maceration, sometimes redness. Rx: antifungal BY Zinabu Dawit(PBsc)

Clinical stage 3 5/1/2024 540 Severe weight loss (>10%) Unexplained chronic diarrhea for longer than one month Unexplained persistent fever (intermittent or constant for longer than one month) Oral candidiasis Oral hairy leukoplakia BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 541 Pulmonary tuberculosis (TB) diagnosed in last two years Severe presumed bacterial infections Acute necrotizing ulcerative stomatitis , gingivitis or periodontitis Unexplained anemia (< 8 g/dl) and neutropenia (<500/mm3) and Thrombocytopenia (<50 000/ mm3) for more than one month BY Zinabu Dawit(PBsc)

Necrotising Gingivitis Inflammation of the gums Extensive and necrotic Tooth loss Anaerobic infection Rx: penicillin, clindamycin, or metronidazole 5/1/2024 542 Gingivitis BY Zinabu Dawit(PBsc)

ORAL HAIRY LEUKOPLAKIA (OHL) Non-removable Vertical white/gray patches/folds on lingual lateral margins (+/- dorsal or ventral surface of tongue) Not painful No treatment Sign of immune suppression 5/1/2024 543 Caused by Epstein-Barr virus (EBV) replication in the epithelium of the surface of the tongue BY Zinabu Dawit(PBsc)

Oral Thrush 60% of patients per year with CD4 < 100 10-20% associated with oesophageal candidiaisis White painless plaques on the buccal or pharyngeal mucosa or tongue surface that can easily be scraped off 5/1/2024 544 Candida albicans is an endogenous yeast Oral thrush BY Zinabu Dawit(PBsc)

Clinical stage 4 5/1/2024 545 HIV wasting syndrome Pneumocystis carnii pneumonia Chronic herpes simplex infection ( orolabial , genital or anorectal of more than one month’s duration) Cytomegalovirus (CMV) infection Recurrent non- typhoidal salmonella septicaemia Lymphoma (cerebral or B cell non-Hodgkin) Invasive cervical carcinoma Visceral leishmaniasis BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 546 Oesophageal candidiasis Extra pulmonary TB Kaposi’s sarcoma Central nervous system (CNS) toxoplasmosis HIV encephalopathy extra pulmonary cryptococcosis including meningitis BY Zinabu Dawit(PBsc)

HIV wasting syndrome Patient is extremely thin(lost >10% of body weight) with chronic fever and/or chronic diarrhea> 1 month 5/1/2024 547 BY Zinabu Dawit(PBsc)

HIV wasting syndrome . 5/1/2024 548 BY Zinabu Dawit(PBsc)

Chronic Mucocutaneous HSV 5/1/2024 549 Genital herpes may become chronic, persisting for months, ulcerating and may cover large parts of the genitals and surrounding skin, causing severe pain and disability. Spread by direct contact. Contagious when lesions are visible and people shed virus even when there are no symptoms. BY Zinabu Dawit(PBsc)

Chronic Mucocutaneous Herpes Simplex: treatment 5/1/2024 550 Acyclovir 200-400 mg 5x/d till resolution Analgetics Suppressive therapy if >6 recurrences/year (acyclovir 200 mg 2x/d) Betadine or potassium permanganate solution sit baths 3 times daily. Zinc oxide to soothe. Alternatively betadine ointment or oxytetracycline ointment 3 times daily BY Zinabu Dawit(PBsc)

CMV oral Ulcerations 5/1/2024 551 May be the first clue to disseminated disease Responds to ganciclovir Requires biopsy for diagnosis Expensive ! BY Zinabu Dawit(PBsc)

5/1/2024 552 Kaposis Sarcoma BY Zinabu Dawit(PBsc)

Cont... 5/1/2024 553 Kaposis Sarcoma BY Zinabu Dawit(PBsc)

5/1/2024 554 Lymphoma BY Zinabu Dawit(PBsc)

Lymphoma . 5/1/2024 555 BY Zinabu Dawit(PBsc)

Presentation of TB Lymphadenopathy 5/1/2024 556 Usual course of TB lymph nodes: firm discrete nodes fluctuant nodes skin breakdown, abscesses, sinuses healing with scarring IN ADVANCED HIV, TB LYMPHADENOPATHY MAY BE ACUTE AND RESEMBLE ACUTE PYOGENIC LYMPADENITIS 70% sensitivity of AFB on aspirate Look also at aspirate: caseation? Can occur even at a relatively high CD4 BY Zinabu Dawit(PBsc)

Cryptococcal Skin Lesions 5/1/2024 557 Sign of disseminated cryptococcosis Nodular, papular, follicular May resemble molluscum! Usually on face, neck, scalp BY Zinabu Dawit(PBsc)

IMMUNOLOGICAL STAGING OF HIV INFECTION 5/1/2024 558 Clinical staging can be used effectively without access to CD4 or other laboratory testing. CD4 testing is useful for determining the degree of immunocompromise and serves as the major laboratory indicator of immune function in patients. It is one of the key factors in determining both the urgency of antiretroviral therapy (ART) initiation and the need for prophylaxis for opportunistic infections. It is also the strongest predictor of subsequent disease progression and survival BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 559 CD4 LEVELS IN RELATION TO THE SEVERITY OF IMMUNOSUPPRESSION 1. Not significant immunosuppression 2. Mild immunosuppression 3. Advance immunosuppression 4. Severe immunosuppression >500/mm3 350 −499/mm3 200−349/mm3 <200/mm3 BY Zinabu Dawit(PBsc)

CRITERIA FOR INITIATING ART 5/1/2024 560 Clinical stage ART Treatment options 4 t reat 3 Consider treatment: CD4, if available, can guide the urgency with which ART should be started 1 or 2 Only if CD4 <200/mm3. BY Zinabu Dawit(PBsc)

ANTIRETROVIRAL DRUGS 5/1/2024 561 Standard ART consists of the combination of at least three drugs, which introduced in 1996 G.C. Typically three are taken in combination the approach is known as Highly Active Antiretroviral Therapy (HAART). In general, three-drug regimens that include three drugs from the same class ( ie , nucleoside analogs) are not as effective as regimens that combine drugs from different classes and are not recommended. The optimal time to initiate treatment is influenced by the benefits and the risks of drug toxicity, potential emergence of viral drug resistance, and the need for lifetime therapy. BY Zinabu Dawit(PBsc)

Goals of therapy 5/1/2024 562 Durable suppression of HIV viral load to less than 50 copies/mL Restoration of immune function (as indicated by the CD4 cell count) Prevention of HIV transmission Prevention of drug resistance Improvement in quality of life BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 563 Why we have to use the combination of three ART drugs. To have sustained viral suppression for long period of time. To attack the virus at different life cycle of the virus To overcome or delay resistance because HIV changes its structure to make ARV less effective . BY Zinabu Dawit(PBsc)

HAART 5/1/2024 564 BY Zinabu Dawit(PBsc)

Classes of ARV 5/1/2024 565 Drug selection is becoming increasingly complex, with more than 20 antiretroviral medications available in six major classes Fusion inhibitors (FIs) CCR5 antagonists Nucleoside (and nucleotide) reverse transcriptase inhibitors (NRTIs) Nonnucleoside reverse transcriptase inhibitors (NNRTIs) Protease inhibitors (PIs) Integrase strand transfer inhibitors (INSTIs) BY Zinabu Dawit(PBsc)

Fusion inhibitors 5/1/2024 566 Were the first class of antiretroviral medications to target the HIV replication cycle extracellularly . Currently, enfuvirtide ( Fuzeon ) is the only product marketed in this class. Act extracellularly to prevent the fusion of HIV to the CD4 or other target cell. Enfuvirtide binds to gp41 and interferes with its ability to approximate the two membranes. BY Zinabu Dawit(PBsc)

Nucleoside (and nucleotide) reverse transcriptase inhibitors (NRTIs) 5/1/2024 567 Less potent against HIV than NNRTIs and Pis , but have had a central role in antiretroviral treatment and remain part of the current standard of care. Are structurally similar to the DNA nucleoside bases interrupt the HIV replication cycle via competitive inhibition of HIV reverse transcriptase and termination of the DNA chain. Tenofovir , lamivudine, and emtricitabine exhibit activity against hepatitis B virus (HBV) in addition to HIV and are frequently incorporated into antiretroviral regimens for patients with HIV and HBV coinfection . BY Zinabu Dawit(PBsc)

Cont … 5/1/2024 568 A total of 7 drugs make up the NRTI class. Abacavir (ABC, Ziagen ) Didanosine ( ddI , Videx ) Emtricitabine (FTC, Emtriva ) Lamivudine (3TC, Epivir ) Stavudine (d4T, Zerit ) Tenofovir (TDF, Viread ) Zidovudine (ZDV, Retrovir ; formerly azidothymidine (AZT) BY Zinabu Dawit(PBsc)

Non-nucleoside Reverse Transcriptase Inhibitors 5/1/2024 569 HIV reverse transcriptase is a heterodimer composed of 2 subunits (p66 and p51). NNRTIs bind the p66 subunit at a hydrophobic pocket distant from the active site of the enzyme. This noncompetitive binding induces a conformational change in the enzyme that alters the active site and limits its activity. Exhibit potent activity against HIV-1 and are part of preferred initial regimens. BY Zinabu Dawit(PBsc)

NNRTIs cont … 5/1/2024 570 First-generation NNRTIs include delavirdine ( Rescriptor ), efavirenz ( Sustiva ) and nevirapine ( Viramune ). Second-generation NNRTIs currently include etravirine ( Intelence ) and rilpivirine ( Edurant ). BY Zinabu Dawit(PBsc)

Protease inhibitors(PIs) 5/1/2024 571 HIV protease is a 99-amino-acid, aspartic acid protein and is responsible for maturation of virus particles late in the viral life cycle. HIV protease inhibitors function as competitive inhibitors that directly bind to HIV protease and prevent subsequent cleavage of polypeptides. They exhibit activity against clinical isolates of both HIV-1 and HIV-2. BY Zinabu Dawit(PBsc)

PIs cont … 5/1/2024 572 A total of 8 compounds are approved for use Atazanavir ( Reyataz ) Darunavir ( Prezista ) Fosamprenavir ( Lexiva ) Indinavir ( Crixivan ) Lopinavir /ritonavir ( Kaletra ) Nelfinavir ( Viracept ) Saquinavir ( Invirase ) Tipranavir ( Aptivus ) NB:- Ritonavir is used as a helper for another PI in adults in to make the effect of other PI stronger. BY Zinabu Dawit(PBsc)

Integrase Inhibitors 5/1/2024 573 The integrase enzyme combines with viral DNA and other cellular cofactors to form the preintegration complex (PIC). These drugs prevent or inhibit the binding of the pre-integration complex to host cell DNA, thus terminating the integration step of HIV replication. The one currently approved integrase inhibitor, raltegravir , and the investigational agent, elvitegravir , both target the strand transfer step of viral DNA integration, and are sometimes referred to as “INSTI” ( Integrase Strand Transfer Inhibitor) drugs. BY Zinabu Dawit(PBsc)

FIRST LINE ART REGIMEN 5/1/2024 574 Will be used in a patient who has no prior ART experience. D4t-3TC-NVP ( 1A ) D4t-3tc-efv ( 1B) AZT- 3TC-NVP (1C) AZT-3TC-EFV (1D) BY Zinabu Dawit(PBsc)

Special first line Regimen . 5/1/2024 575 At times when AZT or d4t cannot used, abacavir (ABC) or tenofovir (TDF) can be used as the first line drugs TDF-3TC-EFV or NVP ABC -3TC –NVP or EFV But currently used drug is TDF+3TC+EFV BY Zinabu Dawit(PBsc)

Second- line regimen 5/1/2024 576 The first line therapy can fail if the drugs are not taken correctly and used for treatment failure it consists of 2NRTIs and 1PI. stronger because the virus has not yet developed a way to avoid the drugs. DDI or TDF +ABC+LPV/r or SQV/r or IND/r or NFV BY Zinabu Dawit(PBsc)

QUIZ 5/1/2024 577 Write the principles synderomic management of of STIs?(1%) List and discuses the approaches to STIs management(2%) 3 List and discuses some factors that affects the transmutations of STIs (2%) BY Zinabu Dawit(PBsc)

Individual assignment for 2nd year BSC nursing student 20% Describe chain of disease transmission Explain Five “ fs ” fecal oral diseases transmission Describe at list the three most common arthropod borne disease Define STIs and Syndromic approach to manage STI Describe the epidemiology of STIs and risk factors. By zinabu D 578

Any Questions 5/1/2024 579 BY Zinabu Dawit(PBsc)

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