ORAL-FECAL TRANSMITTED DISEASES.......pptx

AMBO UNIVERSITY DEPARTMENT OF MIDWIFEY CDC COURSE BY ketema Kenassa

Introduction Definitions of terms Chains of communicable diseases transmission Classification of infectious diseases Natural history of diseases Time lines of infectious diseases Levels of disease prevention Unique features of communicable diseases Factors affecting disease transmission Measurements of occurrences of disease General principles of communicable diseases and control 6/5/2023 cdc introduction 2

Session objectives At the end of this session, participants will be able to: Describe chains of communicable diseases transmission Explain classification of communicable diseases State time lines of infectious diseases Discuss Natural history of the diseases Explain levels of diseases prevention State unique features of communicable disease Explain Factors affecting disease transmission Describe Measurements of occurrences of disease Discuss General principles of communicable diseases and control 6/5/2023 cdc introduction 3

Introduction Communicable diseases : are illnesses due to specific infectious agent or its toxic products which arise through transmission of that agent or its toxic products from an infected person, animal, or inanimate reservoir to a susceptible host, either directly or indirectly, through an intermediate plant or animal host, vector or inanimate environment. are diseases that can spread from person to person or some times animals to people. They occur at all ages but are most serious in childhood 6/5/2023 cdc introduction 4

Introduction… Contd Definition of important terms Infection: The entry and development or multiplication of an infectious agent in the body of humans or animals. The result of this may be in-apparent or manifest. Depending upon the setting in which it may occur: Nosocomial Infection: An infection occurring in a patient in a hospital or other health care facility and in whom it was not present or incubating at the time of admission, or the residual of an infection acquired during a previous admission. Community acquired infection : infection that occurs in the community / general population . 6/5/2023 5 cdc introduction

Introduction…Contd Infestation: The lodgement, development and reproduction of arthropods on the surface of the body or in the clothing. Contamination: The presence of an infectious agent on a body surface; also on or in clothes, bedding, toys, surgical instruments or dressings, or other inanimate articles or substances including water and food. Pollution: The presence of offensive, but not necessarily infectious, matter in the environment. 6/5/2023 6 cdc introduction

Introduction… Contd Disinfection: The procedure of killing infectious agents outside the body by direct exposure to chemical or physical agents. Disinfestation: The procedure of destroying or removing undesired small animal forms, particularly arthropods rodents, present upon the person, the clothing, or in the environment of an individual, or on domestic animals using chemical or physical agents . 6/5/2023 7 cdc introduction

Introduction… Contd Contact (of an infection): A person or animal that has been in such association with an infected person or animal or a contaminated environment as to have had opportunity to acquire the infection. Susceptible : A person or animal presumably not possessing sufficient resistance against a particular pathogenic agent to prevent contracting infection or disease if or when exposed to the agent. 6/5/2023 8 cdc introduction

Introduction… Contd A case of a disease: is a person or animal that manifests clinical evidences (i.e. having signs and symptoms) of the particular disease. Suspect Case : A person whose medical history and symptoms suggest that s/he may have or be developing some communicable disease. A source of infection is a living or non-living thing from which the infectious agent can be passed to a susceptible host. 6/5/2023 9 cdc introduction

Introduction… Contd A host: is a living thing which supports the infectious agent for its survival, and from which the infectious agent can be transmitted to a susceptible host The human being serves as a sole reservoir of infectious agents for certain diseases, like meningococcal meningitis, measles, typhoid fever, gonorrhea, small pox. The human being acts as a reservoir of infection by acting in two ways: as a case and as a carrier 6/5/2023 10 cdc introduction

Introduction…Contd Period of Communicability (Infectious period): The time during which an infectious agent may be transferred directly or indirectly from an infected person to another, from an infected animal to human beings, or from an infected person to an animal, including arthropods. 6/5/2023 11 cdc introduction

Introduction…Contd Incubation Period: The time interval between initial contact with an infectious agent and the appearance of the first sign or symptom of the disease in consideration, or, in a vector, of the first time transmission is possible. The time required for the multiplication of microorganisms within the host up to a threshold where the parasitic population is large enough to produce symptoms 6/5/2023 cdc introduction 12

Introduction…Contd Each infectious disease has a characteristic incubation period, dependent upon : the rate of growth of the organism in the host and Dosage of the infectious agent Portal of entry Immune response of the host Because of the interplay of these factors, incubation period will vary among individuals 6/5/2023 13 cdc introduction

Introduction…Contd 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 to the development of characteristic signs spots and characteristic skin lesions. 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). 6/5/2023 cdc introduction 14

Introduction…Contd Endemic: -A disease that is usually present in a population or in an area at a more or less stable level. Epidemics : -The occurrence of any health related condition in a given population in excess of the usual frequency in that population. Pandemic : -An epidemic disease which occurs world wide (world wide epidemics). Sporadic : -A disease that does not occur in that population, except at occasional and irregular intervals. 6/5/2023 cdc introduction 15

Introduction… Contd Generation time: is the period between the onset of infection in a host and the maximal communicability of that host. The time of maximal communicability may be before or after the incubation period. The concept of generation time is quite crucial in studying the dynamics of transmission of infection. 6/5/2023 16 cdc introduction

Chains of disease transmission Six Factors are required for the occurrence of infectious diseases Infectious agent Reservoir of infection Portal of Exit Mode of Transmission Route of Entry, and Susceptible host 6/5/2023 17 cdc introduction

Chains of disease transmission ... Contd Infectious Agent: This is an organism capable of causing infection or infectious disease. These can generally be grouped into the following five major groups Virus : e.g. HIV; measles; Polio, Herpes, etc. Bacteria : e.g. M. tuberculosi; N. meningitidis; N. gonorrheae Protozoa: e.g. Plasmodia species; E. histolytica; Giardia lamblia, Leishmania species, etc. Fungi: e.g. Candida albicans; Cryptococcus neoformans; Histoplasma capsulatum Metazoa: e.g. Helminths 6/5/2023 18 cdc introduction

Chains of disease transmission ... Contd Reservoir Of Infection: A living thing (human being, animal, arthropod, or plant) or non-living thing (soil etc.,) in which an infectious agent normally lives and multiplies, on which it depends primarily for survival and where it reproduces itself in such a way that it can be passed (transmitted) to a susceptible host. 6/5/2023 19 cdc introduction

Chains of disease transmission ... Contd Animals as reservoir of Infection: Animals as a reservoir of infection for certain of infectious diseases. Some of the common infectious diseases for which animals serve as primary reservoir of infection include: Disease Animal Reservoir Bovine Tuberculosis Cattle Brucellosis Cattle Anthrax Cattle Rabies Dogs 6/5/2023 20 cdc introduction

Chains of disease transmission ... Contd Nonliving things can also serve as reservoirs of agents that cause human infection E.g. Soil for Clostridium tetani , food for Salmonella typhi 6/5/2023 21 cdc introduction

Chains of disease transmission ...Contd Portal Of Exit: This is the site on the reservoir of infection through which the infectious agent escapes from the reservoir. This includes: Gastrointestinal Tract (GIT) e.g. Typhoid fever, amoebiasis etc., Respiratory Tract e.g. Tuberculosis, common cold Skin and Mucous membrane e.g. STDS, Scabies, ring worm 6/5/2023 cdc introduction 22

Chains of disease transmission ... Contd Mode Of Transmission: This is the mechanism by which an infectious agent is transferred from a reservoir of infection to a new host. Two main modes of transmission: Direct Transmission : this refers to the immediate transfer of infectious agents from an infected host or reservoir to an appropriate portal of entry on the susceptible host. Indirect Transmission : this is the transfer of infectious agents from an infected host or reservoir indirectly through airborne particles, vehicles (food, water, etc.,), or vectors to an appropriate portal of entry on the susceptible host. 6/5/2023 23 cdc introduction

Chains of disease transmission ... Contd DIRECT TRANSMISSION Direct contact Droplet infection Contact with soil Inoculation into skin or mucosa Transplacental INDIRECT TRANSMISSION Vehicle borne Vector borne A) mechanical B) biological Air-borne Fomite borne Unclean hands and fingers 6/5/2023 24 cdc introduction

Chains of disease transmission ...Contd A vector is an organism (often an arthropod, such as an insect, mite, and the likes) that transports an infectious agent to a susceptible host or to a suitable vehicle. It is usually responsible for introducing the agent into the host through a suitable portal of entry . 6/5/2023 25 cdc introduction

Chains of disease transmission ...Contd Two types of vectors : A Biological Vector: is one in which a period of multiplication / development of the infectious agent is required before transmission to the host can occur. This period of is called the Extrinsic Incubation Period. Transmission occurs while the vector is feeding on its host by biting A Mechanical Vector : is one in which the agent is directly infective to the host, and hence need not go through a period of multiplication or development. The agent is introduced into the host by vector-host contact, or through contamination of a vehicle 6/5/2023 cdc introduction 26

Chains of disease transmission ... Contd A non-vector intermediate host: intermediate hosts that are necessary only for the development and multiplication of the agent are required to effect transmission. They are not considered as vectors for they do not play an active role in transporting the agent to human host. 6/5/2023 27 cdc introduction

Chains of disease transmission ...Contd A given disease can be transmitted in more than one ways. Identification of the most important (common) mode of transmission should receive prior attention for launching effective control and prevention interventions. 6/5/2023 cdc introduction 28

Chains of disease transmission ... Contd Route Of Entry : The site on the susceptible host through which an infectious agent gets into the susceptible host. Gastrointestinal Tract (GIT) e.g. Typhoid fever, amoebiasis etc. Respiratory Tract e.g. Tuberculosis, common cold Skin and Mucous membrane e.g. STDS, Scabies, ring worm Susceptible Host: This is a person who is highly likely to acquire infection when exposed to the agent. 6/5/2023 29 cdc introduction

Chains of disease transmission ...Contd The likelihood of acquiring infection depends on: Immune status Nutritional status Age Gender Hygienic practices Race Personal habits 6/5/2023 cdc introduction 30

Chains of disease transmission ... Contd 6/5/2023 31 cdc introduction

Classification of human infections by selected features Feature Specifics Example A. Mode of Spread through Human Population: Common Vehicle Spread: Ingestion Salmonellosis Inhalation Tuberculosis Inoculation Serum hepatitis Serial Transfer from host to host Anal - oral route Shigellosis Genital route Gonorrhea Respiratory route Tuberculosis B. Main Reservoir of infection Human being Measles Other vertebrates (Zoonoses) Brucellosis Non-living things (e.g. soil) Tetanus 6/5/2023 32 cdc introduction

Classification of human infections ... Contd Feature Specifics Example C. Route of Entry and Exit in the Human Host Respiratory Tract Upper Diphtheria Lower Tuberculosis Gastrointestinal tract Salmonelosis Genitourinary tract Gonorrhea Mucus membrane (Conjunctiva) Trachoma Skin (bite of insect) Yellow Fever D. Life cycle of infectious agent Human to Human Measles Human  Arthropod  Human Malaria Complex cycles Schistosomiasis 6/5/2023 33 cdc introduction

Carrier is an infected person or animal that does not have clinical signs and / or symptoms of the disease but serves as a potential source of infection to others (Susceptible). Exposure to infectious agents: No infection Clinical Sub-clinical Carrier Death Carrier Immunity No immunity Outcome 6/5/2023 34 cdc introduction

Carrier...contd Types of Carriers Healthy / Asymptomatic / Carrier: in this type of carrier state infection remains inapparent, i.e. No signs and / or symptoms suggesting clinical disease are manifest e.g. Meningococcus, hepatitis B virus. Incubatory / precocious / Carriers: These are infected individuals who excrete the pathogen during the incubation period, i.e. before the onset of clinical disease. e.g. Measles, mumps, hepatitis Convalescent Carriers: These are people who continue to harbor and excrete the infectious agent after recovering from the illness. e.g. Salmonella typhi, hepatitis B, . Chronic Carriers: In this type, the carrier state persists for a long period of time or indefinitely. e.g. Salmonella typhi, hepatitis B virus. 6/5/2023 35 cdc introduction

Carrier...contd The Importance of Carriers Number: Difficulty in recognition Mobility Chronicity 6/5/2023 36 cdc introduction

Natural history of diseases Course of development of infectious diseases over time. Are the health outcomes in ill persons who are not receiving a therapy that influence the rate of the outcomes. It is the course of illness in the absence of intervention. 6/5/2023 cdc introduction 37

Natural history of diseases … Contd Stage of Susceptibility Sub clinical Stage Clinical Stage Stage of Outcome EXPOSURE INFECTION DISEASE DISEASE OUTCOME TIME 6/5/2023 38 cdc introduction

Natural history of diseases …Contd Stage of susceptibility this is a stage in which disease has not developed but the ground work has been laid by the presence of factors that favor its occurrence. Susceptible person is lacking sufficient resistance to particular pathogenic agent to prevent disease if or when exposed. 6/5/2023 cdc introduction 39

Natural history of diseases …Contd Incubation period It is the time interval between the entry of pathogenic micro organism and sufficient multiplication to cause pathology that will produce signs and symptoms of disease . 6/5/2023 cdc introduction 40

Natural history of diseases …Contd Stage of pre symptomatic disease or sub clinical stage there is no manifest disease i.e. no signs and symptoms are detected. The person does not know that he has any disease. The sub clinical stage of disease may lead to the clinical stage or the individual may recover. An inapparent infection or silent infection is a successful infection that does not develop detected symptoms. Inapparent cases can be infectious. 6/5/2023 cdc introduction 41

Natural history of diseases …Contd The clinical stage in this stage the person has symptoms and signs of disease. There are various grades of illness with different outcomes depending on the agent host interaction. Some diseases are short and mild that every one recovers quickly while others are very serious leading to complications and death. 6/5/2023 cdc introduction 42

Natural history of diseases …Contd Stage of disability some diseases run their course and then resolve completely either spontaneously or under the influence of therapy. However there are a number of conditions which give rise to residual defects of short or long term duration leaving the person disabled to a greater or lesser extent. 6/5/2023 cdc introduction 43

Timeline of Infection Infection Susceptible Susceptible Dynamics of infectiousness Dynamics of disease Incubation period Symptomatic period Non-diseased Latent period Infectious period Non-infectious Infection Time Time 6/5/2023 44 cdc introduction

Time line of infection …Contd Dynamics of infection: susceptible, latent period, infectious period and non infectious (removed , dead, recovered). Time line for infection is important for the parasite/agent and public health Dynamics of disease: susceptible, incubation period, symptomatic period, non diseased (dead, removed, immune, carrier). Time line for disease is important to infected person and physician/health worker 6/5/2023 cdc introduction 45

Levels of disease prevention The different points in the progression of a disease at which one can intervene to prevent further out come. three levels of disease prevention Primary Secondary and Tertiary preventions 6/5/2023 cdc introduction 46

Levels of disease prevention … Contd Primary prevention : The objectives here are to: promote health prevent exposure and prevent disease . Health promotion : any intervention that promotes a healthier and happier life. This consists of general non-specific interventions that enhance health and the body's ability to resist diseases such as: improvement of socio economic status through provision of adequately paid jobs, education and vocational training, affordable and adequate housing, clothing and food , emotional and social support, relief of stress etc. 6/5/2023 cdc introduction 47

Levels of disease prevention … Contd Prevention of exposure : any intervention which prevents the coming in contact between an infectious agent and a susceptible host. This includes actions such as : provision of safe and adequate water proper excreta disposal; vector control safe environment at home, at school and at work, on the streets . 6/5/2023 cdc introduction 48

Levels of disease prevention … Contd Prevention of disease : - This occurs between exposure and the biological onset of the disease. EX. immunization. Breast feeding is an example of intervention that acts at all three levels of primary Prevention. 6/5/2023 cdc introduction 49

Levels of disease prevention … Contd Secondary prevention: After the biological on set of the disease, but before permanent damage sets in. 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 diseases. Breast cancer (prevention of invasive stage of the disease) Trachoma (prevention of blindness) Syphilis (prevention of tertiary or congenital syphilis) 6/5/2023 cdc introduction 50

Levels of disease prevention … Contd Tertiary prevention : After permanent damage sets in, the objective of tertiary prevention is to limit the impact of that damage. The impact can be physical (physical disability), psychological, social(social stigma),and financial. Ex. Rehabilitation 6/5/2023 cdc introduction 51

Unique Features of Infectious Diseases A case may also be a source: For infectious diseases such as influenza, a person’s risk is greatly affected by the number of influenza patients around, and if many of the people have been vaccinated. Cases: Index : the first case identified Primary : the case that brings the infection into a population Secondary : infected by a primary case Tertiary : infected by a secondary case 6/5/2023 52 cdc introduction

Unique Features of Infectious Diseases… contd Some people may be immune: For some infectious diseases, such as measles, once a person has had the disease, he/she will never get it again. Thus, in terms of measuring incidence, not everyone is “at risk” of developing the disease. 6/5/2023 53 cdc introduction

Unique Features of Infectious Diseases… contd There is sometimes a need for urgency: With outbreaks of some infectious diseases, such as Ebola disease, the time frame for investigation and preventive action may be a matter of hours or days . this may give little time for elaborate analyses. Preventive measures (often) have a clear scientific basis. For many infectious diseases, the causative agent and characteristics of transmission are well established this leads to clear (but not always easy) targets for disease prevention. 6/5/2023 54 cdc introduction

FACTORS AFFECTING DISEASE TRANSMISSION and SYMPTOMATIC CLINICAL DISEASE 6/5/2023 cdc introduction 55 Host Vector Agent Environment Susceptibility Immune response Resistance Virulence Toxigenicity Infectivity Resistance Pathogenicity Antigenicity VECTOR Prevalence Balance of immune to susceptible individuals Opportunity for exposure (e.g. crowding )

Host-parasite interactions These interactions determine the occurrence and expression of infectious processes Microorganisms have specific properties in the course of such interaction and can be characterized by their ability to interact with a host and produce a range of possible outcomes. These characteristics are dependent on the interaction between the agent and the host. 6/5/2023 56 cdc introduction

Host-parasite interactions … Contd 6/5/2023 cdc introduction 57 Why exposure to microorganisms is not always followed by infection? Why infection is not always followed by the development of a manifest disease? Does infection with a given infectious agent result in a disease of same degree of severity in all individuals?

Host-parasite interactions … Contd Infectivity: is the ability of an agent to invade and multiply (produce infection) in an exposed host. Infectivity is a measure of the progression of an infectious agent from exposure to infection Many host and environmental factors as well as the dose, the route of entry, source of infection, and the strain of the agent influence the infectivity of an agent. 6/5/2023 58 cdc introduction

Host-parasite interactions … Contd Pathogenicity: is the ability of an agent to produce a clinically manifest disease in susceptible host. . It is measured by determining the proportion of infections that result in clinically apparent disease 6/5/2023 59 cdc introduction

Host-parasite interactions … Contd Virulence: this is the ability of an agent to produce severe disease. It is measured by determining the proportion of clinical cases resulting in severe clinical manifestations, including sequelae . Some of measures of virulence as it applies to humans are: the case fatality rate (CFR) proportion of cases disabled or who have developed sequelae proportion of cases who required a different kind of treatment (e.g. hospitalization, surgical intervention, etc.) than that is usually needed for most cases from a the same kind of illness . 6/5/2023 60 cdc introduction

Host-parasite interactions … Contd Strictly speaking, infectivity, pathogenicity, and virulence are not intrinsic properties of microorganisms. 6/5/2023 61 cdc introduction

Host-parasite interactions … Contd Factors that influence the degree of infectivity, pathogenicity, and virulence include: Strain of agent Dose of agent Route of infection Host factors like host age, host nutritional status, host immune response Treatment, especially on virulence and Season 6/5/2023 62 cdc introduction

Intrinsic properties of Microorganisms…Contd Antigenicity: refers to the ability of the agent to induce immune response and thus an immune state in the host. Agents vary in this capacity: Toxigenicity: refers to the capacity of the agent to produce a toxin, or poison. The effect of agents in diseases such as botulism poisoning depends upon the toxin produces by the microorganism rather than on the microorganism itself. Resistance: refers to the ability of the agent to survive adverse environmental conditions during transmission from one host to another. Some agents are remarkably resistant, while others are extremely fragile. 6/5/2023 63 cdc introduction

Measurement of the occurrence of diseases Measurement is the basis for evidence based practice: The two fundamental principles of epidemiology that a given health event does not occur by chance and that its distribution is not uniform in any population necessitate for measurement in order for properly understanding and hence making necessary decisions; The understanding of the occurrence, consequences, the need for services and the effect of targeted interventions as related to a given health event cannot be substantiated without making the proper measures . Why Measurement? 6/5/2023 64 cdc introduction

Measurement of the occurrence of diseases... contd Occurrences of Diseases : Risk factors Cases Spread Consequences of Diseases: Disabilities, Deaths Need for/ burden on/ services Hospitalization rates Effect of targeted interventions Cases/ disabilities/deaths averted Quality of care What Can be Measured? 6/5/2023 65 cdc introduction

Measurement of the occurrence of diseases… contd Index Case Person that comes to the attention of public health authorities Primary Case Person who acquires the disease from an exposure to index cases Attack rate Secondary Case Person who acquires the disease from an exposure to the primary case Secondary attack rate –This is a measure of the degree of spread 6/5/2023 66 cdc introduction

Measurement of the occurrence of diseases… contd Ate the food (exposed) Did not eat the food (not exposed) Ill Well Total Attack Rate Ill Well Total Attack Rate 10 3 13 76% 7 4 11 64% Calculation of Attack Rate for Food X 6/5/2023 67 cdc introduction

Measurement of the occurrence of diseases… contd Age in Years Population Cases Total No. susceptible before primary cases occurred Primary Secondary 2-4 300 250 100 50 5-9 450 420 204 87 10-14 152 84 25 15 Secondary Attack Rate 6/5/2023 68 cdc introduction

Measurement of the occurrence of diseases… contd Secondary Attack Rate Used to estimate to the spread of disease in a family, household, dorm or other group environment. Measures the infectivity of the agent and the effects of prophylactic agents (e.g. vaccine) 6/5/2023 69 cdc introduction

principle of prevention and control of communicable diseases Is based on consideration of cycle of transmission where efforts are made to break this chain by employing appropriate interventions specific to the particular infectious disease that ultimately aims at completely ceasing or reducing the transmission of the specific communicable disease. This depends on the degree of complexity (simplicity) of the transmission cycle of the particular communicable disease. 6/5/2023 70 cdc introduction

general principles in the prevention and control of communicable diseases… contd Communicable diseases share common considerations in the general principle or approach in terms their control and prevention. How is it possible to have General Principles for the Prevention and control of Communicable Diseases? 6/5/2023 71 cdc introduction

General principles in the prevention and control of communicable diseases… contd The general principles in the control and prevention are based upon the consideration of three factors involved in the chain of disease transmission: The Reservoir The Mode of Transmission, and The Susceptible Host 6/5/2023 72 cdc introduction

General principles in the prevention & control of cds … contd The specific types of control measures aiming on the human being depends on its specific reservoir role as a CASE or a CARRIER of the particular disease Human being as a Case Case –detection and treatment: the process of identifying and treating people with the disease so as to render them unimportant as a source of infection, by reducing the communicability of the disease. Active case detection: active search for cases of a given disease ensures the early identification of people with the disease before the disease puts an irreversible . Measures directed at the Reservoir: HUMAN 6/5/2023 73 cdc introduction

General principles in the prevention & control of cds … contd Screening: detecting cases at earlier stages of disease development on apparently well people. Screening as an initial examination is not usually diagnostic and requires appropriate investigative follow -up and treatment. It is a vital tool for control & prevention of diseases that benefit from active case -detection and treatment. Isolation: the separation, for the period of communicability of the disease, of infected persons or animals from others so as to prevent or limit the transmission of the infectious agent from those infected to those who are susceptible to infection or who may spread the agent to others. Isolation is not indicated for every CD Measures directed at the Reservoir : HUMAN 6/5/2023 74 cdc introduction

General principles in the prevention & control of cds … contd Isolation is indicated for infectious diseases having: High morbidity High mortality High infectivity Easily recognizable infectious cases; The use of isolation is often variable from country to country, partly depending up on the level of development of the health care services Measures directed at the Reservoir: HUMAN 6/5/2023 75 cdc introduction

General principles in the prevention & control of cds … contd Quarantine : the limitation of the movement of apparently well people who are considered to have been exposed to a source of infection for the maximum duration of the incubation period Measures directed at the Reservoir : HUMAN 6/5/2023 76 cdc introduction

General principles in the prevention & control of cds … contd When animals are the reservoirs of infection, decision on the type of measures to be taken should consider: The relation of the animal with human beings The usefulness of the animal The feasibility of protecting susceptible animals Measures directed at the Reservoir : Animals 6/5/2023 77 cdc introduction

General principles in the prevention & control of cds … contd Measures directed at the Reservoir : Animals 6/5/2023 78 cdc introduction

General principles in the prevention & control of cds … contd Limit the exposure of people to the affected or suspected area. e.g., soil, water, etc Measures directed at the Reservoir : Non living things 6/5/2023 79 cdc introduction

General principles in the prevention & control of cds … contd These measures are meant to break or interrupt the chain of transmission from the reservoir to the susceptible host Vector control Improving environmental sanitation and personal hygiene Disinfection and sterilization Health Education Measures directed On the MODE OF TRANSMISSION 6/5/2023 80 cdc introduction

General principles in the prevention & control of cds … contd Increasing the host resistance Immunization( Active,Passive ) Chemoprophylaxis Decreasing or minimizing exposure of the host Measures Directed On The Protection Of The Susceptible Host 6/5/2023 81 cdc introduction

References Jan Eshuis and peter Manschot , communicable diseases , a manual for rural health workers African medical and research foundation, Nairobi © 1978. Abram S. Benson, 14 th edition, control of communicable disease in man interdisciplinary books pamphlets and periodicals, Washington 1985. Alemayehu M. Communicable Disease Control lecture note. Hawassa University : Ethiopia Public Health Training Initiative, The Carter Center , the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education,2004. 4. Communicable Diseases Part 1 General principles, vaccine-preventable diseases and malaria, MOH, Addis Ababa. 5 . Epidemiologic Aspects of Infectious Diseases, Bioterrorism Epidemiology Module ;Missouri Department of Health,2004. 6/5/2023 cdc introduction 82

References…Contd 6. Guidelines on prevention of communicable diseases in school /Kindergartens/kindergarten-cum-child care centre/child care centre. Centre for Health Protection , Department of Health , January 2009 7. Cameron S. Health and Communicable DiseasesEdition .Public health buletine ;2006 6/5/2023 cdc introduction 83

ORAL-FECAL TRANSMITTEDDISEASES 2023 By kk 84

Learning Objectives At the end of this chapter, students will be able to: Identify the five important “Fs” in oral-fecal disease transmission. State diseases transmitted mainly in water and in soil. List diseases commonly transmitted by having direct contact with feces. Implement preventive and control methods of oral-fecal transmitted diseases. 85

The causative organisms of oral-fecal transmitted diseases are excreted in the stools of infected persons (or, rarely, animals). The portal of entry for these diseases is the mouth. Therefore, 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. 86

The five “Fs” of fecal oral diseases The five “Fs” which play an important role in fecal oral diseases transmission finger, flies, food, Fluid and fomites 87

Feces Mainly in Water The diseases in this group are mainly transmitted through fecally contaminated water rather than food. Typhoid fever Bacillary Dysentery (Shigellosis) Amoebiasis (Amoebic Dysentery) Giardiasis Cholera Infectious hepatitis 88

1.Typhoid fever( Enteric fever) A systemic infectious disease characterized by high continuous fever, malaise and involvement of lymphoid tissues. Infectious agent Salmonella typhi Mild infection with salmonella paratyphi A & B. a ll of which are non capsulated, gram negative motile bacteria 89

It can survive in water for 1 week & in sewage for two week, and it can be killed by boiling of water, milk, etc. 6/5/2023 90

Epidemiology Occurrence- It occurs worldwide, particularly in poor socio economic 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 of age). Reservoir- Humans 91

Countries endemic for typhoid  (U.S. CDC 2006) Alex LaPointe, Wikimedia Commons 92

Typhoid fever remains a significant health burden, Regional typhoid fever IR ranged from <0.1 /100 000 cases/y in Central and Eastern Europe and Central Asia to 724.6 /100 000 cases/y in SSA. Regional paratyphoid IR ranged from 0.8 /100 000 cases/y in North Africa/Middle East to 77.4 /100 000 in SSA & South Asia. The estimated total number of typhoid fever episodes in 2010 was 13.5 million (9.1-17.8 ). 6/5/2023 94

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. Incubation period –1-3 weeks 95

Period of communicability- As long as the bacilli appear in excreta, 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% of the cases become chronic carriers. Susceptibility and resistance- Susceptibility is general and increased in individuals with gastric achlorhydria or those who are HIV positive. 96

PATHOGENESIS 6/5/2023 97

Ingestion of contaminated food or water Salmonella bacteria Invade small intestine and enter the bloodstream Carried by white blood cells in the liver, spleen, and bone marrow Multiply and reenter the bloodstream

Bacteria invade the gallbladder, biliary system, and the lymphatic tissue of the bowel and multiply in high numbers Then pass into the intestinal tract and can be identified for diagnosis in cultures from the stool tested in the laboratory

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. 100

Clinical manifestation First week Mild illness characterized by Fever is high grade, with a daily increase in a step-ladder pattern for the first one week and then becomes persistent. Headache (intense) , malaise/Fatigue , Abdominal pain Initially diarrhea or loss stole followed by constipation in adults, diarrhea is dominate feature in children 6/5/2023 101

First week continued.. Relative bradycardia : Slower than would be expected from the level of temperature. Splenomegally and Hepatomegaly Epistaxis “ Rose spots ” not commonly seen in black patients. In whites it appears as small, pale red, blanching macules commonly over chest & abdomen, lasting for 2-3 days. 6/5/2023 102

“Rose spots,” the rash of enteric fever due to S. typhi or S. paratyphi . 6/5/2023 103

Rose spots High fever Diarrhea Typhoid Meningitis Aches and pains Chest congestion

Second week Fever becomes continuous s/s of DHN The patient becomes very ill and withdrawn confused, delirious and sometimes may be even comatose Wt loss 6/5/2023 105

Third Week The patient goes to a pattern of “ typhoidal state" characterized by extreme toxemia , disorientation , and “pea-soup” diarrhea and sometimes may be complicated by intestinal perforation and hemorrhage. 6/5/2023 106

Fourth Week Fever starts to decrease and the patient may deferveresce with resolution of symptoms . significant wt loss. Relapse may occur in 10% of cases . If no complications occur, patient begins to improve and temperature decreases gradually. 6/5/2023 107

Sometimes may be complicated: Gastrointestinal bleeding (10–20 %) and intestinal perforation (1–3%) most commonly occur in the third and fourth weeks of illness and result from hyperplasia, ulceration, and necrosis of the ileocecal Peyer’s patches at the initial site of Salmonella infiltration 6/5/2023 108

Complication: GI hemorrhage, perforation, peritonitis, Enteric encephalopathy ( typhoid psychosis) , myocarditis , endocarditis , osteomyelitis , & arthritis, Pancreatitis , Splenic & hepatic abscess. Meningitis, Bronchitis and pneumonia 6/5/2023 109

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 first week 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. 110

Chronic Carriers Approximately 1- 5 % of patient with Enteric fever become asymptomatic chronic carriers They shed S.typhi in either urine or stool for > 1 year Incidence of Chronic carriage is high in women and among patients with biliary abnormality (e.g. gall stone, carcinoma of gall bladder) and other GI malignancies. 6/5/2023 111

Diagnosis Can be suggested by the presence of Persistent fever Relative bradycardia, which was found to occur in 86% of Ethiopians . Rose spots, which occurs in 70% of whites and 20% of Ethiopians. 6/5/2023 112

Diagnosis,,,,,,,,,, But definitive diagnosis of the disease requires laboratory tests. 1. Isolation of the organism by blood, stool or urine culture is diagnostic. The yield of recovery of the organism differs depending on the specimen cultured and the duration of clinical disease. 6/5/2023 113

Isolation continue… Blood culture – Mostly (up to 90%) patients have positive culture in the 1st week, and only 50% by the 3rd week. The yield is much lower if patient has taken antibiotics prior to the test. Stool culture It is negative in the first week and becomes positive in 75% of patients in the 3rd week. Urine culture parallels stool culture. 6/5/2023 114

Dx … Bone marrow aspirate cultures give the best confirmation (85-95%) Bone marrow culture often is the most sensitive test for S. typhi Complete blood count: Leucopoenia- <40 00/mm3 6/5/2023 115

Widal test for O and H antigens The O(somatic ) antigen shows active infection whereas the H ( flagellar ) antigen could be indicative of past infection or immunization for typhoid. to make a diagnosis of current infection a 4X ( fold) rise in titer on paired sera taken during the acute and convalescence phases is necessary . 6/5/2023 116

Limitations of Widal test It is non specific and a positive test could be due to Infection by other salmonellae Recent vaccination for typhoid Past typhoid (already treated) 6/5/2023 117

Treatment Antibiotic therapy is curative . PO /IV Fever may persist for 4-6 days despite effective antibiotic treatment. 6/5/2023 118

Oral drugs First Line Nowadays 4-amino quinolones are the drugs of choice because of: Their effectiveness on multidrug resistant typhoid, and low relapse and carrier rates. Ciprofloxacin , norfloxacin , ofloxacin , and pefloxacin are all equally effective . Ciprofloxacin: 500mg PO BID for 10 days Ceftriaxone 1-2 gm IM or IV for 10 -14 days 6/5/2023 119

Continued… Alternative Azithromycin 1 gm PO daily for 5 days Chloramphenicol 500 mg Po QID for 14 days Norfloxacin 400mg BID for10 days 6/5/2023 120

IV drugs recommended for critically sick patients who are admitted or for patients who are unable to take oral drugs Ceftriaxone 2-4gm once a day for 3 days and then 1- 2gm IV/IM for a total of 10- 14 days. IV Chloramphenical 1gm IV QID for 2-3 days and then start PO medication as soon as the patient can take oral medication. Chloramphenical is a drug of choice for patients that need parenteral therapy especially in Ethiopia (mainly for cost reason). 6/5/2023 121

Nursing care Nursing care 1. Maintain body temperature to normal. 2. Apply comfort measures. 3. Follow side effects of drugs. 4. Monitor vital signs. 5. Follow strictly enteric precautions: wash hands wear gloves teach all persons about personal hygiene 122

6. 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 7. Accurately record intake and output. 8. Provide proper skin and mouth care. 123

Prevention and control 1. Treatment of patients and carriers 2. Education on hand washing, particularly food handlers, patients and childcare givers 3. Sanitary disposal of feces and control of flies. 4. Provision of safe and adequate water Safe handling of food. Exclusion of typhoid carriers and patients from handling of food and patients 124

7. Immunization for people at special risk (e.g. Travelers to endemic areas)  Typhim Vi®; Vivotif ® 8. Regular check-up of food handlers in food and drinking establishments 125

2 . Shigellosis (Bacillary dysentery) Acute bacterial disease involve large intestine and distal part of small intestine. Infectious agent : shegella ( gm-ve , non-motile bacilli) Four important species: S.dysentry S.flexinerie S.boydii S. sonni 126

Epidemiology world wide Endemic in developing countries Became epidemic in overcrowding situation like jail, refuge campus ,poor personal hygiene ....especially S. dysentery Most common cause of death of under 10 year old (60%) Reservoir: human MT : -Direct- physical contact e.g. Contaminated hands-to-oral -In direct-eating or drinking contaminated foods or drinks 127

pathogenesis Organism enters to intestine Inflammation and ulceration Hemorrhage and ulceration 128

Cont,d IP : 1-3 days CM : fever, headache N\V, abdominal pain Tenesmus, bloody diarrhoea ….. Complication : Electrolyte in balance Sepsis Rectal prolaps Toxic mega colon haemolytic uremic syndrome 129

Cont,d Dx : microscopic stool examination Stool culture Rx : fluid and electrolyte replacement Antibiotic - Ciprofloxacin 500mg po BID for 7 days - cotrimexazol 960mg po BID for 7-10days - Nalidixic acid10-15ml po QID Prevention and control Health education Proper disposal of wastes Environmental sanitation Proper food handling, preparation, Personal hygiene.. 130

3. CHOLERA Acute bacterial enteric disease. Infectious agent : Vibro cholerea( gm-ve motile bacteri Epidemiology : outbreak especially serotype 01,0139 Reservoir : human environmental (water???) MT : ingestion of contaminated water by faeces or vomitus of infected person 131

pathogenesis Ingestion of contaminated water Production of entero toxin Stimulate adenylate cycle(AMP path way)-secretary factor Sudden onset of profuse watery diarrhoea (rice water) IP : few hours to 5 days 132

Cont,d Dx : sign and symptom Dark field stool microscopy Stool culture Rx : fluid and electrolyte replacement Antibiotic like TTC, Ciprofloxacin, Norfloxacin... CFR = up to 50% without Rx less than 1% with Rx Death usually due to shock & renal failur 133

Prevention and control Case report Isolation Proper disposal of faeces and vomits Case Rx Safe water supply Personal hygiene Vaccination Surveillance.. 134

4. Enteric Fever(typhoid & para typhoid Systemic bacterial infection of the intestine Infectious agent- genus Salmonnella(gm-ve bacilli) S.typhi-cause typhid fever S. paratyphi-cause paratyphiod fever Epidemiology- worldwide -common in poor socio-economic status Reservoir- human(both case and carrier) MT- ingestion of food or drinks contaminated by feces or urine of pt or carrier(fly may contaminate) 135

pathogenesis ingestion contaminated of food or drinks Organism enters and penetrate intestinal mucosa Migrate to regional LNs and multiply Enters to blood streams (bacteremia) & involve liver & gall bladder IP : 1-3 weeks 136

Clinical manfestation 1 st week -gradual onset of fever -headache, malaise, anorexia -constipation -brandycardia 2 nd week -fever continuous -diarrhea -rose spot( small pallor, macules, on the chest, abdomen 3 rd week - fever continuous -abdominal distention -delirium, drowsiness 4 th week - recovery and relapse may occur(upto 10%) 137

Suggestive S/S(cardinal) Fever ladder type Rose spot Relative bradycardia Leucopoenia Dx : culture(blood, bone marrow.. serologic test(Widal test-detection of O & H Abs) stool/urine exam-starting from 2 nd week PCR( detection of Vi Ags) 138

Rx Antibiotic -ciprofloxacin - Ceftriaxon - CAF Surgical - cholecystectomy Complication -intestinal hemorrhage and perforation - myocarditis -psychosis -Encephalomyelitis - Cholecystitis , choliangitis -chronic carrier state 139

Prevention and control Safe drinking water Safe waste disposal Proper storage of foods and drinks Public education Control flies Screening of carrier Vaccination- effective up to 70% for 3 year Environmental sanitation 140

5. Amoebiasis A protozoa infection of intestinal or extra-intestinal disease Infectious agent : E. Histolytic E. Coli-found in GIT E. Gingivalis-found in mouth Epidemiology : world wide Common in tropical and sub-tropical area High prevalent in poor sanitation MT : feco-oral (ingestion of food or drinks contaminated by feces containing cyst) Cyst- stage in the life cycle of parasite during which enveloped by protective wall IP : variable, commonly 2-4 weeks Reservoir : human 141

Life cycle and transmission Transmission Environment Human host 142 1.cyst ingested in foods, /hands Contaminated with faeces 2. cyst excyst → form trophozoite 3. multiply in intestine 4.trophozoite encyst → infective cyst 5. infective cyst passed in faeces Environment Faeces containing infective cyst contaminate the environment (food, water)

Cont,d CM : abdominal cramp and discomfort N/V , anorexia Diarrhoea( watery containing mucus/or blood) tensmus.. Dx : microscopic examination of stool Rx ; Metrindazle\ Tinindazole Diloxanide 143

Prevention and control Rx of cases-( metrindazole / Tinindazole for trophozoite form) - Diloxanide for cyst Safe drinking water Proper disposal of excreta Personal hygiene Cleaning and cooking of foods 144

6. Gardiasis Protozoan infection principally the upper small intestine Infectious agent - Gardia lambia Epidemiology -world wide -highly prevalent in areas of poor sanitary conditions -children are more affected Reservoir -human Life cycle and MT –similar with Ameabiasis 145

Sustability and resistance High asymptomatic carrier state Infection is usually self limited More serious and prolonged in pt with HIV/AIDS CM: abdominal cramp and discomfort N/V , anorexia Diarrhoea( watery containing mucus/or blood) tensmus.. Dx : microscopic examination of stool Rx ; Metrindazle\ Tinindazole Prevention and control -simillar 146

7. Ascariasis A helmentic infection of small intestine Infectious agent : Ascaris lumbricoids Epidemiology : most common human parasite High prevalent area with poor sanitation School children are most affected High in moist tropical countries Reservoir: human Ascarid eggs in soil IP : 4-8 weeks 147

Life cycle and transmission Transmission Environment Human host 148 1.infected eggs ingested in foods, or from hands Contaminated with faeces 2.larvae hatch migrate through Liver and lungs 3. Pass up trachea and swallowed 4. became mature worms in small intestine 5. Eggs produced & passed through feces 6.egg became infective (embryonated in soil in 30-40 days) 7. Infective eggs contaminate the environment

Clinical manifestations most infection are asymptomatic Abdominal pain and discomfort Migrate larvae may cause itching, wheezing, dyspnoea.. Series complication include bowel obstruction 149

Cont,d Dx : Hx(adult worm might pass via anus, mouth, or nose) microscopic exam. Rx : Albendazole Mebendazole Piperazine Livamisol. Prevention and control : similar with other IP 150

8. Tricuriasis A nematode infection of large intestine Infectous agent-Trichuris trichuria(whip worm) Epidemiology -world wide -common in warm areas -highly prevalent in areas of poor sanitary conditions -children are more affected(3-11 yrs old) Reservoir -human IP: indefinite 151

Life cycle and transmission Transmission Environment Human host 152 1.Infected eggs in foods, /hands Contaminated with faeces 2. Larvea hatch reach intestine→migrate to ceacum 3. Became mature worms insmall intestine 4.Eggs produced and passed through feces 7. Infective eggs contaminate the env,t 6.Eggs became infective (embryonated ) in the soil after 3 wks

Clinical manfestation Usually asymptomatic Abdominal pain, tiredness, N/V, diarrhea, constipation Rectal prolapsed especially in children Dx : microscopic exam. of stool( demonstration of eggs Rx : Albendazole Mebendazole Prevention and control : similar with other IP 153

9. Entrobiasis ( Oxyuriasis , pin worm) A helementic infection of intestine Infectious agent- Entrobius vermicularies Epidemiology -world wide -highly prevalent in areas of poor sanitary condition Reservoir -human IP : 2-6 weeks 154

Life cycle and MT 155 Adult worms in ceacum Gravid female migrate through the anus to perianal area and skin, deposit eggs usually during the nights Eggs became infective in few hours in periana area Migrate down to caecum Larva hatch in duodenum Ingestion of eggs by man

Clinical manifestation Perianal itching Irritability, disturbed sleep Secondary infection as the result of scratched skin Dx ; microscopic exam. of stool( demonstration of eggsor female worm) Rx : Mebendazole Prevention and control -similar 156

10. Strongyloidiasis A helmintic infection of the duodenum and jejunum Infectious agent : strogyloid stercoraris Epidemiology : common in warm and wet regions Common in tropical and temperate areas Reservoir : human 157

Life cycle and MT 158 1. Infective flariform larvae penetrate skin 8.Infective filariform larvea contaminate env’t 7. Infective flariform larvea(within a week) 6.Rhabiditiform larvae hatch, feed in soil 2. Larva migrate, pass up trachea and are swallowed 3. Became mature worms in small intestine 4. Eggs laid, hatch rhabiditiform larvae in intestine 5.Rhabiditiform larvae Passed in feces Became filariform Larvae in intestine causing auto infection

Cont,d CM : epigastric discomfort Mild peptic ulcer type disease Pneumonia during heavy larva migration heavy infection –mal-absorption syndrome 159

Cont,d Dx ; microscopic exam. of stool (demonstration of larva Rx : Albendazole Thiabendazole Prevention and control Proper disposal of human excreta Personal protection Rx of cases 160

11. Hook worm( Ancylostomiasis / Necatoriasis ) A chronic parasitic infection of the intestine with a variety of symptoms usually in proportion of degree of anemia Infectious agent : Ancylostoma duodenale Necator americanus Epidemiology : common in warm and wet regions endemic in tropical and sub-trpical areas highly prevalent in area with poor sanitation soil moisture & Temperature favour development of larva Reservoir : human 161

Life cycle and MT 162 1. Infective flariform larvae penetrate skin 7. filariform larvae contaminate env’t 6. Develop in to Infective larvae (about a week) 2. Larva migrate, pass up trachea and are swallowed 3. Became mature worms in small intestine 4. Eggs produced and passed in feces 5. Eggs develops, rhabiditiform larvae, hatch, feed in soil

Cont,d.. IP: few weeks to many years CM : transient, localized muculo-papular rash itching sensation at the site of penetration heavy larva migration -pneumonia heavy infection – symptoms of PUD Dx ; microscopic exam. of stool ( demonstration of eggs in the stool) Rx : Mebendazole Albendazole Levamisol Prevention and control Proper disposal of human excreta Personal protection Rx of cases 163

ZOONOTIC DISEASES 6/5/2023 By :ketema kenassa 165 Group of disease transmitted from vertebrate animal to human under normal condition. For most of these diseases, man is a dead-end of the transmission cycle. ----under normal conditions, man will not infect other human beings.

11. Viral Hepatitis An acute viral infection (inflammation ) of the liver Cause-HAV (infectious hepatitis -HBV( serum hepatitis) -HCV( non A non B hepatitis) -HDV( hepatitis delta) -HEV 166

Viral Hepatitis(cont,d…. Reservoir -human MT -feco-oral route(HAV, HEV) -parentral, sexual, perinatal(HBV, HDV) -blood transfusion, exposure to contaminated blood or equipment(HCV) IP - 4weeks(HAV) -8-12 weeks(HBV) -6-9 weeks(HCV) -4-8 weeks (HDV) - 2-6 weeks(HEV) 167

Cont,d ….. CM -low grade fever -anorexia -upper abd. Discomfort -malaise -dark urine -jaundice -tender hepatomegally 168

Cont,d… Complication increase risk of- chronic hepatitis -cirrhosis -hepatic cancer Dx -serology -clinical feature 169

Cont,d … Rx - supportive (ex bed rest.. -intensive care( in case of fulminate) -liver transplantation -interferon (to prevent chronic disease) Prevention and control improve basic sanitation safe injection practice screening blood and blood products Vaccination(A & B) 170

8.1 Rabies 6/5/2023 By :ketema kenassa 171 An acute, usually fatal infectious viral disease of the CNS Infectious agent : Rabies virus ( DNA virus family-rhabido viridea with genus iyssa virus Epidemiology: ♦world wide ♦Primary it is a disease of animals ♦Endemic in Africa, Asia The case to fatality rate is the highest of any infectious disease

Cont,d 6/5/2023 By :ketema kenassa 172 Reservoir: domestic and wild animals like dogs, foxes, wolves, bats, raccoons… MT : through close contact with saliva from infected animals (i.e. bite, scratch,… Frequently human became infected with rabies through the bite of rabid dogs and cats.

RABIES HOSTS 6/5/2023 By :ketema kenassa 173 All warm-blooded vertebrates are susceptible to experimental infection Mammals are the natural hosts of rabies Reservoirs consist of the Carnivora (canids, skunks, raccoons, mongoose, etc.) and Chiroptera (bats)

Cont,d 6/5/2023 By :ketema kenassa 174 IP : variable but usually 3-8 weeks however, IP became short when The bite is on the face The victim is young The injury is sever or multiple There is no pre or post exposure prophylaxis

6/5/2023 By :ketema kenassa 175

RABIES PATHOGENESIS 6/5/2023 By :ketema kenassa 176 Virus is transmitted via bite Agents are highly neurotropic Enter peripheral nerves Centripetal travel by retrograde flow in axoplasm of nerves to CNS Replicate in brain Centrifugal flow to innervated organs, including the portal of exit, the salivary glands Viral excretion in saliva

CM...... 6/5/2023 By :ketema kenassa 177 Has three stages (phase) 1. Prodormal phase- sense of apprehension -parasthesia, tingling sensation -headache, fever 2. Excitatory phase- aerophobia - irritability, restless, nervosness - tendency to bite - Lucid interval 3.Paralytic phase- dysphagia -hydrophobia -drolling of saliva - delirium

6/5/2023 By :ketema kenassa 178

Complication: 6/5/2023 By :ketema kenassa 179 ♦encephalitis ♦Meningitis ♦Cranial nerve palsies ♦Seizure, ♦ Opisthotonic spasm Respiratory muscle spasm → death

Cont,d 6/5/2023 By :ketema kenassa 180 Dx ; •Hx •Direct fluorescent antibody test •PCR on saliva •Brain biopsy-detection antigens Negri bodies •Mouth inoculation and culture

6/5/2023 By :ketema kenassa 181 Rx: ▼wound care -no suturing ▼Anti-rabies vaccination(passive artificial vaccine Induced coma Administered high doses of ketamine to suppress brain activity Required mechanical ventilation Administered heparin Administered ribavirin , an antiviral, to protect the heart from rabies-induced cardiomyopathy Days 8-10 showed improvement in cardiovascular and neurological functions By day 23 she could sit up in bed, but neurological manifestations persisted Required prolonged physical therapy, but is continuing to recover This treatment failed for a Texas boy

RABIES RECOVERY? 6/5/2023 By :ketema kenassa 182 5 historical human case recoveries, after vaccination, but before illness onset Only one documented unvaccinated human survivor after clinical presentation

Prevention and control 6/5/2023 By :ketema kenassa 183 Immunize all dogs, cats… Keep dogs and cats at home Destroy street animals where rabies is endemic PEP -Rabies Vaccines (for pre- and PEP) Rabies immune globulin (only in PEP) One dose of hyperimmune antiserum Five immunizations over 28 days

RABIES VACCINES 6/5/2023 By :ketema kenassa 184 Two Human Rabies Vaccines in USA: Human Diploid Cell Vaccine Imovax® (HDCV) Purified Chick Embryo Cell RabAvert® (PCEC)

POSTEXPOSURE PROPHYLAXIS 6/5/2023 By :ketema kenassa 185 Wash lesions well with soap and water (tetanus booster ad hoc) Infiltrate rabies immune globulin (20 IU/kg) into and around the margin of the bites Administer vaccine on days 0,3,7,14, and 28

POSTEXPOSURE PROPHYLAXIS 6/5/2023 By :ketema kenassa 186 Urgency rather than emergency, per se Depends in part upon the animal species, exposure details, rapidity of diagnostic testing, and epidemiology of rabies in the local area Consultation with knowledgeable public health officials should be routine

8.2 Anthrax 6/5/2023 By :ketema kenassa 187 Acute bacterial disease usually affects the skin but sometimes the oropharnyx, LRT, mediastinum and GIT. Infectious agent : Bacillus anthrasis (aerobic,gm-ve) Epidemiology : primary a disease of herbivorous Occupational hazard disease High risk groups includes-hiders -veterinaries -wool makers -Agriculture or wild workers

MT 6/5/2023 By :ketema kenassa 188 Through contact with contaminated wool, hair, skin, tissue (cutaneous anthrax) Inhalation of spores during wool processing/bio-terrerisom (inhalational l anthrax) Consumption of contaminated meat products(GI) IP : 1-7 days

The Anthrax Cycle 6/5/2023 By :ketema kenassa 189

Clinical manifestation 6/5/2023 By :ketema kenassa 190 skin (95%)-red macule→papule→vesicles→postules→ulcer (black necrotized scar) -regional lymphadenitis -80-90% heals spontaneously but oedema can exist - 10-20% infection progress and lead to even to death Inhalational -dyspnoea - Hypoxia -fever, mediastinitis GI -N\V -Fever, abdominal pain, bloody diarrhoea

Cont,d 6/5/2023 By :ketema kenassa 191 Dx : Clinical data Gram stain of lesion Culture, PCR Rx : Penicillin CAF Ciprofloxacin Erythromycin

Prevention and control 6/5/2023 By :ketema kenassa 192 Decontamination of wools hairs. Improve work condition Vaccination (high risk groups, animals..) carcass of animal should be buried intact Avoiding butcher of animals Public education

8.3 Toxoplasmosis 6/5/2023 By :ketema kenassa 193 Systemic protozoal disease , intra cellular parasite Can be acute or chronic Infectious agent : Toxoplasma gondii Epidemiology : world wide Common in mammals and birds Common in warm climate Reservoir : cat (main reservoir for human infection) MT : -by ingesting oocysts excreted in cat faeces -by eating under cooked meat -transplacentally -Organ transplantation –rarely

C M 6/5/2023 By :ketema kenassa 194 many human infection are asymptomatic Fatigue, mylagia Lymphadenitis Chills, fever, headache… Hepatomegally ( rarely) Encephalitis Congenital toxoplasmosis Intracranial calcification Chorio-retinitis→ blindness Mental retardation Microcephally N.B During pregnancy toxoplasmosis leads to still birth, abortion, and premature labour.

Cont,d 6/5/2023 By :ketema kenassa 195 Dx : History of contact with cats, ingestion of raw meat.. Serological test Lymph nodes biopsy PCR Rx : pyrimethamin and sulphadiazin\Clindamycin For congenital toxo-- pyrimethamin and sulphadiazin\Spiramycin Steroids-in chorio-retinitis For pregnant women –spiramycin through out the pregnancy -pyrimethamin and sulphadiazin at the first trimester

Prevention and control 6/5/2023 By :ketema kenassa 196 Avoide eating of un/ under cooked meat Personal hygiene hand washing Control street cats Avoidance of cat faces, cat hunting prophylaxis for immnocompromized individuals e.g. bacterium prognosis : 10%- CFR 10%-sever neurological ccn

8.4 Brucellosis 6/5/2023 By :ketema kenassa 197 A systemic bacterial infectious caused by a genus Brucella (aerobic, gm- ve bacilli, intracellular parasite) Infectious agent : Brucella mellitensis (goat and sheep) “ abortus ( cattle ) “ suis( pigs ) “ canis ( dogs ) Epidemiology : world wide 500,000 cases every year) Public health problem in developing countries High risk groups includes-farm workers and veterinaries

x 6/5/2023 By :ketema kenassa 198 Reservoir : cattle, goats, sheep, pigs, dogs MT : ingestion of contaminated meat, milk, cheese Inhalation of infected materials when handling, slaughtering Inoculation through broken skin or mucus membrane Sexually Blood transfusion --very rarely Vertical transmission IP : 1-3 weeks

Cont,d …. 6/5/2023 By :ketema kenassa 199 CM : entering to host cell taken by macrophages of reticuloendothelial system and initiate granulomatous reaction Abrupt onset of fever, chills, headache, maylagia. Anorexia Joint and back pain Cough Lymphadenopaty Hepato-spleenomegally Complication: arthritis Oesteomyelitis Endocarditis Meningitis myocarditis Neuritis pneumonia Encephalitis Orchids

Cont,d 6/5/2023 By :ketema kenassa 200 Dx : Hx Laboratory-ESR, cell count ( leucopoenia, lymphocytosis Culture (blood, bone marrow, urine..) Biopsy Serological tests Rx : combined treatment for 6-8 week Doxycyclin + Aminoglycosides(STM) for 2 weeks then doxycyclin + rifampicin for 4-8 weks Pregnant and children -bacterium +Rifampicin for 8-12 weeks

Prevention and control 6/5/2023 By :ketema kenassa 201 Avoid consumption of raw meat, milk… Elimination of reservoir (infected animals) Public education Pasteurization of milk , cooking of meat.. Use of barriers for risk groups Proper disposal of placenta, discharge from aborted animals Disinfection of contaminated areas

8.5 Taeniasis (Tape worm) 6/5/2023 By :ketema kenassa 202 A cestode infection of the intestine Elongated ribbon like worm up to 25 meter Infectious agent : Taenia saginata (beef tape worm Taenia solium (pork tape worm) Epidemiology : world wide disease Frequent when beef or pork is eaten raw Frequent where sanitary condition permits pigs and cattle to have access to human faeces. Reservoir : human are definite host for both species Pigs -intermediate host for T. saginata Cattle-intermediate host for T. Solium IP : few days to many years (10 years)

Life cycle and mode of transmission 6/5/2023 By :ketema kenassa 203 Cyst cerci ingested with under cooked meat ↓ Cyst cerci attached to the wall of intestine by using scolex ↓ Gain in length by producing chain of segments ( progloittids ) ↓ Became mature tape worm (gravid) ↓ Egg released when gravid segment became detached ↓ Eggs and gravid segment passed with faeces ↓ Reach the ground where animals feed ↓ Eggs ingested ↓ Embryos carried to muscles and develop in to infective cyst cerci

CM 6/5/2023 By :ketema kenassa 204 usually asymptomatic Passage of proglottides Perianal discomfort Abdominal pain and discomfort Change in appetite

Cont,d 6/5/2023 By :ketema kenassa 205 Dx ; appearance of proglottides Microscopy examination of stool( demonstration of eggs in feaces) Rx : Niclosamide Paraziquantin Dechlorophin Mebendazole Albendazole Surgical –in case of cysticercosis( T.solium)

Prevention and control 6/5/2023 By :ketema kenassa 206 Public education regarding uses of latrine, cooking meats… Early Dx and Rx of cases Proper storage of foods e.g. freezing, salting … Sanitary disposal of wastes

Thank you All 6/5/2023 By :ketema kenassa 207

CHAPTER 9 6/5/2023 By :ketema kenassa 208

CHAPTER 9 FOOD POISONING 6/5/2023 By :ketema kenassa 209

6/5/2023 By :ketema kenassa 210 9.1 Introduction Food-born diseases are terms applied to illnesses acquired by consumption of contaminated food. They are frequently and inaccurately referred to as food poisoning. While those terms would include illnesses caused by chemical contaminants/heavy metals and organic compounds), this bacterial growth in the food before consumption (staphylococcus aureus and botulism) and a food-borne infection ( salmonellosis ).

Food poisoning....... 6/5/2023 By :ketema kenassa 211 Micro-organisms occur naturally in the environment, on cereals, vegetables, fruit, animals, people, water, soil and in the air. Most bacteria are harmless but a small number can cause illness. Food which is contaminated with food poisoning micro-organisms can look, taste and smell normal.

People at high risk 6/5/2023 By :ketema kenassa 212 For example, pregnant women or anyone with low resistance to infection should avoid high risk foods such as unpasteurised soft cheese.

Factors affecting food poisoning 6/5/2023 By :ketema kenassa 213 Some common factors leading to food poisoning include: preparation of food too far in advance; storage at ambient temperature; inadequate cooling; inadequate reheating; under cooking; inadequate thawing.

6/5/2023 By :ketema kenassa 214 Interferes with carbohydrate metabolism Neurotoxins Enterotoxins Muscle Liver Food borne diseases Food poisoning Food Infections Chemical poisoning Enterotoxigenic Poisonous animal tissues Bacterial toxins Mycotoxins Algal toxins Invasive Sporulation Growth & Lysis Intestinal mucosa Systemic Other tissues Intoxications Poisonous plant tissues Microbialintoxication

6/5/2023 By :ketema kenassa 215 Food Poisoning/ Intoxication: This is a food borne disease arising from the ingestion of: Toxins released by MOs, Intoxication from poisonous plants or toxic animal issues; or Due to consumption of food contaminated by chemical poisons. Following are typical examples of food poisoning/ intoxication diseases.

9.2 staphylococcal food poisining 6/5/2023 By :ketema kenassa 216 It is intoxication (not infection) of abrupt and some times violent onset. Infections agent (toxic agent) Staphylococcus aureus stable at boiling t o Staph.epidermides, and Staph.saprophyticus. EPI: wide spread and relatively frequent Reservoir : Humans in most instances; occasionally cows with infected udders

6/5/2023 By :ketema kenassa 217 MOT - By ingestion of contaminated food High water content, high protein and low acidic food (e.g. Potato , sandwiches, sliced meat and meat products pastries poultry, milk, milk products etc). The organisms may be of human origin from purulent discharges of an infected finger or eye, abscesses, nasopharyngeal secretions. I/p : 30 minutes to 8hrs, usually 2-4 hrs POC - not applicable S/R – Most people are susceptible

6/5/2023 By :ketema kenassa 218 Clinical Mxs Sudden onset of vomiting and watery diarrhoea Fever and abdominal cramp Salivation Severe nausea, Abdominal cramps Sweating Headache The intensity of illness may require hospitalization

6/5/2023 By :ketema kenassa 219 Diagnosis Xic acute predominantly UGI symptoms and short interval between eating a common food item and the onset of symptoms Culture- may be –ve for the bacteria staphylococcal recovery (greater than or equal to 10 organisms per gram of food) or detection of enterotoxin from an epidemiologically implicated food item confirms the diagnosis

6/5/2023 By :ketema kenassa 220 Rx. Fluid and electrolyte replacement if fluid loss is significant particularly in severe cases Prevention and control Educated food handless in strict food hygiene, sanitation and cleanliness of kitchens, proper temperature control, hand washing, cleaning of finger nails, need to cover wounds on the skin. Reduce food handling time (initial preparation to service) to an absolute minimum, with no more then 4hrs at ambient temperature. Keep perishable food hot (>60 C or cold (below 10 C). Temporarily exclude people with boils, abscesses and other purulent lesions of hands, face or nose from food handling.

9.3 Botulism 6/5/2023 By :ketema kenassa 221 A paralytic disease that begins with cranial nerve inv't and progresses caudally to involve the extremities. Infectious agent (Toxic agent) Toxin produced by clostridium botulinum (Neurotoxin) EPI World wide occurrence. Home canned foods, particularly vegetables, fruits and less commonly with meat and fish. Outbreaks have occurred from contamination through cans damaged after processing. Commercial products occasionally cause outbreaks but some of these outbreaks have resulted from improper handling after purchase. Food born botulism can occur when a food to be preserved is contaminated with spores Reservoir - soil and in the intestine of animals

6/5/2023 By :ketema kenassa 222 MOT - Food infection in which preformed toxin is found. I/P : Neurological symptoms of food borne botulism usually appear within 12-36 hours, some times several days, after eating contaminated food POC : not communicable S and R –Susceptibility is general

6/5/2023 By :ketema kenassa 223 The toxin is one of the most potent neuro toxin produced by microbes. The toxin is heat liable (destroyed by heating) Eight serotypes of the organism are known (A-H) But 4 types are associated with human illness (A,B,E,F) The organism is widely distributed in nature, hence readily to contaminate foods

6/5/2023 By :ketema kenassa 224 Clinical Manifestations Illness varies from a mild condition to very severe disease that can result in death within 24 hours. Symmetric descending paralysis is characteristic and can lead to respiratory failure and death. Cranial nerve inv't makes the onset of symptoms, usually produces diplopia (double vision) dysphasia (difficult in swallowing). Weakness progresses' often rapidly, from the head to involve the neck, arms, thorax and legs; the weakness is occasionally asymmetric. N/V/D Abd pain may proceed or follow the onset of paralysis.

cm…. 6/5/2023 By :ketema kenassa 225 Dizziness blurred vision dry mouth, and occasionally sore throat are common. No fever; ptosis is frequent Papillary reflexes may be depressed: fixed or dilated pupils are noted in half of patients The gag reflex may be suppressed; deep tendon reflexes may be normal or decreased Paralytic ileus (a decrease in or absence of intestinal peristalsis), severe constipation and urinary retention are common.

PTOSIS 6/5/2023 By :ketema kenassa 226

6/5/2023 By :ketema kenassa 227 Diagnosis Appropriate history Clinical- Afebrile, mentally intact patients who have symmetric descending paralysis with out sensory findings Demonstration of organisms or its toxin in vomitus, gastric fluid or stool is strongly suggestive of the diagnosis Wound culture POLIO?? GBS

6/5/2023 By :ketema kenassa 228 Treatment Hospitalize the pt and monitor closely Intubation and mechanical ventilation may be needed Antitoxin administration after hypersensitivity test to horse serum Emesis and lavage if short time after ingestion of food to decrease the toxin Antibiotics for wound botulism Penicillin

Prevention and control. 6/5/2023 By :ketema kenassa 229 Ensure effective control of processing and preparation of commercially canned and preserved food Education about home canning and other food preservation techniques regarding the proper time, pressure and temperature required to destroy spores. The need for adequate refrigeration, storage, boiling with stirring home-canned vegetables for at least 10 minutes to destroy botulinal toxin. Canned foods in bulging containers should not be eaten or tasted.

6/5/2023 By :ketema kenassa 230 9. salmonellosis A bacterial disease commonly manifested by an a cute enterocolitis (inflammation involving both the large & small intestines) Infectious agent - Salmonella typhimurium and salmonella enteritidis are the two most commonly reported EPI : It occurs world wide Reservoir - Domestic and wild animals including poultry, swine, cattle, rodents and pets (tortoises, doges, cats, and humans) and patients or convalescents are carriers esp. of mild and unrecognized cases.

6/5/2023 By :ketema kenassa 231 MOT - ingestion of organisms in food derived from infected food animals or contaminated by faeces of an infected animal or person, raw and under cooked eggs and egg products, raw milk and its products, poultry and its products consumption of raw fruits and vegetables contaminated during slicing (cutting in to pieces) I/P : from 6-72 hours, usually about 12-36 hours POC - extremely variable through the course of infection; usually several days to several weeks S and R – Susceptibility is general and increased by achlorhydria , antacid therapy, GI surgery, prior or current broad spectrum antibiotic Rx, neo plastic disease, immuno suppressive Rx and malnutrition.

6/5/2023 By :ketema kenassa 232 Clinical Mx. Self limited fever and diarrhoea (Bloody or dysenteric when colon is involved) Nausea, vomiting and abdominal cramp Microscopic leukocytosis DX – Blood culture initially - Stool culture Rx – Symptomatic If there is an underlying immunosuppressive disease (condition like AIDS, lymphoma, immunosuppressive treatment) treat the underlying cause

6/5/2023 By :ketema kenassa 233 Prevention and control Improved animal rearing and animal marketing Quality testing of the known and commonly contaminated foods Avoid consuming raw or partially cooked EGGS Wear gowns and gloves when handling stool and urine and hand washing after patient contact.

THANK YOU 6/5/2023 By :ketema kenassa 234

COMMENTS 6/5/2023 By :ketema kenassa 235

References: 6/5/2023 By :ketema kenassa 236 Jan Eshuis and peter Manschot , communicable diseases , a manual for rural health workers African medical and research foundation, Nairobi © 1978 Abram S. Benson, 14 th edition, control of communicable disease in man interdisciplinary books pamphlets and periodicals, Washington 1985. National guide line on HIV /AIDS . MOH Addis Ababa , 1998 National guide line on selected epidemic diseases in Ethiopia , MOH, Addis Ababa . National guide line on MTCT, MOH Addis Ababa National Management guide line on Malaria for health workers in Ethiopia, MOH, Addis Ababa National Guide line on prevention and control of malaria in Ethiopia MOH, Addis Ababa Mansons tropical diseases, 4 th edition UK

237 ARTHROPOD OR INTERMEDIATE VECTOR-BORNE DISEASES

VECTOR/ARTHROPOD BORE DISEASE: 238 Learning Objectives At the end of this chapter, the student will be able to: Describe what arthropod or intermediate vector-borne disease means. Identify the 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.

Introduction 239 a vector is any carrier of disease, but in the case of the ‘vector-borne diseases’ we restrict the word to those invertebrate hosts (insects or snails), which are an essential part of the life cycle of the disease organism. A housefly just carrying bacteria or amoebic cysts on its feet to food is not regarded as a vector: this would be simple mechanical spread.

240 Insect vectors usually acquire the disease organism by sucking blood from infected persons, and pass it on, later, by the same route. There are other routes, however; infection may enter skin cracks or abrasions either from infected feces deposited when feeding, or from body fluid when an insect is crushed.

241 vector bore-indirect MT vector can be Biological -requires a period of multiplication /development before transmission(extrinsic IP) ex. malaria Mechanical - directly infect to the host (no need of extrinsic IP) ex. Fly

Types of Vector born Diseases 242 Mosquito-borne …. Flea born…. Louse-borne …..

Mosquito-borne 243 A. Malaria: An acute infection of the blood caused by protozoa of the genus plasmodium. Infectious agent -4 types:- Plasmodium falciparum Plasmodium vivax Plamodium ovale Plasmodium Malariae

Mosquito-Borne Diseases 244 Epidemiology: -endemic in tropical and sub- tropical -Affects 40% of world population -High risk group- < 5 children - pregnant -traveller to endemic area -Attitude <2000m but now a days can be detected up to 2300 m above sea leave due to climatic and ecologic changes

Epidemiology (cont,d) 245 I n Ethiopia 68-75% malaria area(3/4) PR= P.f =60%, P.v =40% leading cause of M&M Reservoir -human

246 Endemicity of malaria is defined based on spleenic rates (palpable spleen) in children between 2 & 9 years. Depending on this, regions are classified in to 4 endemicity areas:-

247 Hypo endemic - Where < 10% children have enlarged spleen Meso -endemic - Where 10-50% children have enlarged spleen Hyper-endemic - Where 51-75% of children have enlarged spleen Holo -endemic - Where > 75% of children have enlarged spleen "

MT of Malaria 248 1.by the bite of infected female A. mosquito 2. Blood transfusion 3. Organ transplantation 4. Hypodermic needle 5. Mother-to-child

Susceptibility and resistance 249 Susceptibility is universal except in some host-resistance 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.

250 IP : vary-Pf: 7-14 days - Pv : 8-14days - Pv : 8-14days - P.m : 8-30 days

Life cycle 251 Transmission 1. Sporozoite inoculate when Anopheles takes a blood meal

Life cycle ( cont,d ) 252 Human host 2. Sporozoite infect liver cell multiply by schizogony , some sporozoite of P. vivax and P. ovale became dormant ( hyponozoite )in liver became active after several month ↓ 3. Liver schizonts rupture merozoite , enter RBC became trophozoite (multiply by schizogony ) ↓ 4. Schizonts rupture merozoite infect new RBC ↓ 5. some merozoite develop in to male and female gametocyte.

Life cycle (cont,d) 253 Mosquito 9. Oocyst rupture sporozoite reach Salivary gland ↑ 8. Sporozoite form in oocyst ↑ 7. male and female gametocyte fuse zygote oocyst in the stomach wall. ↑ 6. gametocyte ingested by mosquito

Cont,d 254 CM A. Simple uncomplicated pf chills fever headache arthralgia mylagia N/V, anorexia

CM of Malaria… 255 B. Sever complicated ( P.f ) – anemia-( normochromic ) -due to hemolysis & bone marrow suppression RF, oliguria -due to acute tubular necrosis cerebral malaria- due to adhesion of capillaries pulmonary edema-due to obstruction of capillaries and this leads to anoxia

Complication ( cont,d …. 256 hypoglycemia- due to high parasitic load lactic acidosis-due to persistent vomiting Disseminated intra vascular coaglopathy (DIC) spontaneous bleeding Shock -due to concomitant bacterial infection

Chronic Complications of Malaria 257 Chronic anaemia Spleenic rupture Nephrotic syndrome Tropical Spleenomegally Syndrome (TSS)

Tropical Splenomegaly Syndrome ( Hyperreactive malarial Splenomegaly ) 258 It is a syndrome resulting from an abnormal immunologic response to repeated infection. Is seen is some residents of malaria endemic area in tropical Africa and Asia

TSS is characterized by : 259 Huge spleen ( > 10 cm BLLCM ) with or with out hepatomegaly Hyperspleenism ( anaemia , pancytopenia ) Marked elevation of serum IgM and anti malarial antibody Hepatic Sinusoidal lymphocytes Peripheral B-Cell lymphocytosis

Clinical Feature: 260 Abdominal mass or dragging sensation in the left upper quadrant and sometimes abdominal pain Anaemia and sometimes Pancytopenia  susceptibility to Infection The parasite may not be detected in peripheral blood film

Treatment of TSS 261 Antimalarial prophylaxis for a long time, usually for the duration of malaria exposure. Drugs commonly used are chloroquine or mefloquine . The enlarged spleen and liver usually regress over a period of months with effective Antimalarial prophylaxis. Splenectomy is only indicated for those with failure of antimalarial prophylaxis at least given for 6 months.

Malaria in pregnancy 262 More than 23million pregnant women live in malaria endemic area and few of them have access to medical care, particularly in Sub-Saharan Africa. As a result malaria is becoming one of the major indirect causes of maternal death along with HIV/AIDS.

263 Pregnant women, particularly in the second and third trimesters are more likely to develop severe malaria than other adults, often complicated by pulmonary edema and hypoglycemia. Maternal mortality is 50% high than in the non-pregnant period. The commonest complications are; maternal anemia, spontaneous abortion, still birth, premature labours , and low birth weight.

Dx of Malaria History-CM Epidemiological pattern Direct microscopy(BF) RDT Serologic 264

265 NOTE: A single blood film examination doesn’t rule out malaria, and it should be repeatedly done possibly during febrile episodes. However, studies have shown that BF can be negative in small percentage of patients with malarias

Other Lab Tests of Severe Malaria 266 Hemoglobin- anemia can be detected Blood glucose Peripheral morphology- Normocytic normochromic anemia - Low or normal WBC LP and CSF analysis ( when indicated to R/O Meningitis ) BUN/ Cr, SGOT , SGPT , Serum electrolytes etc

Prevention and control 267 1. Early Dx and Rx -1 st line -for P.f is Coartum -for P.vivax-chloroque -2 nd line – Quinin (PO,IV in sever case 2.Vector control -insecticide treated mosquito net -repellents, aerosol -house screening -site selection -chemoprophylaxis

Prevention cont,d … 268 3.Chemical control- insecticide spray aerosols ( deltamethrin and bendocarbon ) - larvicide DDT 4.Biological control- larvivorish fish -biological larvicide -toxin producing bacteria

Prevention cont.d… 269 5. Environmental management covering /discarding man made container clearing vegetation filling pools, springs, land depressions intermittent irrigation drainage for swampy or marshy areas

Medical mgt 270 Uncomplicated P. Falciparum malaria First line Coartum =( Artemether + Lumefantrine , 40mg + 240mg) P.O. BID for 3 days S/Es: nausea, vomiting, diarrhea C/I: first trimester pregnancy

271 Alternative Quinine dihydrochloride , 600 mg TID for 7 days. S/Es: Cinchonism  including tinnitus, headache, nausea, abdominal pain, rashes, visual disturbances, confusion, blood disorders (including thrombocytopenia and intra-vascular coagulation), and acute renal failure. C/I: Hemoglobinuria , optic neuritis

Rx Severe & Complicated of Malaria 272 A. Quinine dihydrochlorid e : Admit the patient Open IV line Loading dose: 20 mg/kg in 500 ml of 5 % dextrose over 4 hours (4 ml/minute). The pediatric dose is the same but the fluid replacement must be based on body weight.

273 Maintenance dose : should be given 8 hours after the loading dose at a dose of 10 mg / kg and it should be given 8 hourly diluted in 500 ml of 5 % dextrose over 4 hours. The parenteral treatment should be changed to P.O. as soon as the patient‘s condition improves and if there is no vomiting.

274 Oral treatment should be given with Artemether + Lumefantrine in the doses as indicated above. However, if a patient has a history of intake of Artemether + Lumefantrine before complications developed, give Quinine tablets 10 mg salt per kg TID to complete 7 days treatment.

275 Note: Wherever IV administration of quinine is not possible. Quinine dihydrochloride 20 mg salt per kg loading dose intramuscularly (IM) divided in to two sites, anterior thigh). Then quinine dihydrochloride 10 mg salt per kg IM every 8 hours until patient can swallow.

276 B. Artesunate injection : 2.4 mg/kg IV or IM stat followed by 1.2 mg/kg at 12 and 24 hrs and then daily. N.B. Almost all deaths are caused by falciparum malaria

Non-Drug treatment /Nursing mgt of Severe and complicated P. f malaria 277 Clear and maintain the airway. Position semi-prone or on side. Weigh the patient and calculate dosage. Make rapid clinical assessment. Exclude or treat hypoglycemia (more so in pregnant women). Assess state of hydration.

Nursing care of Severe Malaria pt… 278 Measure and monitor urine output. - If necessary insert urethral catheter. Measure urine specific gravity. Administer glucose IV or PO to prevent hypoglycaemia and encourage early PO intake of food

Nursing care of Severe Malaria pt… 279 Take blood for diagnostic smear, monitoring of blood sugar (' stix ' method), haematocrit and other laboratory tests. Plan first 8 hrs. of intravenous fluids including diluents for anti-malarial drug, glucose therapy and blood transfusion. If rectal temperature exceeds 39°C, remove patient's clothes, use tepid sponge,

Nursing care of Severe Malaria pt… 280 Lumbar puncture to exclude meningitis or cover with appropriate antibiotic. Consider other infections. Consider need for anti- convulsant treatment Advise patient to come back if the illness gets severe. Advise on personal protection (bed nets, etc). Reduce fever and maintain comfort.

FILARIASIS 281 A disease caused by the reaction of the body to the presence of worms in the lymphatic system. filarial worm belongs to the class nematodes Also known as Lymphatic Filariasis or elephantiasis The word elephantiasis describes: the gross (visible) enlargement of the arms, legs, or genitals to elephantoid size.

Epidemiology 282 Elephantiasis, puts at risk more than a billion people in more than 80 countries. Over 120 million have already been affected by it, over 40 million of them are seriously incapacitated and disfigured by the disease. One-third of the people infected with the disease live in India, one third are in Africa and most of the remainder are in South Asia, the Pacific and the Americas.

283 Widely prevalent in tropical and subtropical areas of Africa, Asia, Pacific Region, Central and South America. Found in Gambella region (western Ethiopia).

Infectious agent 284 It is caused by thread-like parasitic worms such as Wucheriria bancrofti (vectors are culex , Anopheles and Aedes species) Brugia malayi (vector is mansonia species) and Brugia timori (vector is Anopheles) More than 90 percent of these infections are due to W. bancrofti , and the remainder is mostly due to B. malayi .

285

Host Factors 286 Man – Natural Host Age – All age Sex – Higher in men Migration – leading to extension of infection to non-endemic areas

Pathogenesis of filariasis  Chronic Manifestation 287 Obstruction of the lymphatic vessels leads to swelling in the lower torso, typically in the legs and genitals Chronic (Obstructive) lesions takes 10-15 years. This is due to the permanent damage to the lymph vessels caused by the adult worms,

Chronic Manifestation... 288 the pathological changes causing dilation of the lymph vessels due to recurrent inflammatory episodes leading to endothelial proliferation and inflammatory granulomnatous reaction around the parasite.

289 Initially, it starts with pitting oedema which gives rise to browny oedema leading to hardening the tissues. Still late, hyper pigmentation, caratosis , wart like lesions are developed. N.B . recurrent lymphatic inflammation can cause obstruction and edema in legs, genitalia and scrotal –Elephantiasis Eg . Hydrocele (40-60%), Elephantiasis of Scrotum, Penis, Leg, Arm, Vulva, Breast

liquid jigsaw - life-cycle of lymphatic filariasis animation 290

MT 291 By the bite of mosquito( culex , aedes .. inject larva Migrate to the lymphatic ,mature into adults and produce microfilaria( 6-12 months) Adult worm living within lymphatic ,causing .inflammation -chills, fever - epididimitis - lymphangitis -lymphadenitis . Obstruction . Fibrosis

Clinical Manifestations 292 Manifestations are 2 types Lymphatic Filariasis (Presence of Adult worms) Occult Filariasis (Immuno hyper responsiveness) Clinical Spectrum None Asymptomatic microfilaremia Filarial fever Chronic pathology TPE

Acute phase: 293 Starts within a few months after infection Lymphadenopathy Fever Eosinophilia In this stage 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.

294 Tropical pulmonary eosinophilia — Tropical pulmonary eosinophilia is characterized by nocturnal wheezing. It is caused by an immune hyperresponsiveness to microfilariae trapped in the lungs and is typically seen in young males.

295 A clinical syndrome characterized by marked blood eosinophilia , paroxysmal nonproductive cough, wheezing, occasionally weight loss, lymphadenopathy , and low-grade fevers was initially described in tropical areas early in the last century, and more fully documented about 40 years ago

296 The syndrome has been variously termed tropical eosinophilia , tropical pulmonary eosinophilia (TPE), or tropical filarial pulmonary eosinophilia (TFPE). It represents a distinct immunologic reaction to infection with the human lymphatic filarial parasites Wuchereria bancrofti or Brugia malayi TFPE develops in less than 0.5 percent of patients with lymphatic filariasis .

C/M: Subacute phase: 297 This occurs after about one year following acute phases. In this phase worms have matured and micro filariae 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 hypereosinophilia and lung symptoms (tropical pulmonary eosinophilia syndrome).

C/M: Chronic phase: 298 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 legs 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.

Leg 299

Arm 300

Stages of Lymphoedema of the Leg (Stage I) Swelling reverses at night Skin folds-Absent Appearance of Skin-Smooth, Normal 301

302

303

304

305

Swelling not reversible at night Skin folds-Absent, Shallow, Deep Appearance of skin *Wart-like lesions on foot or top of the toes 306

307

Breast 308

Hydrocele 309

Scrotum 310

Penis 311

Cont,d .. 312 Dx - BF -serology ( detect filarial Abs) -clinical & epidemiological ground - X-ray Diagnosis: helpful in the diagnosis of Tropical pulmonary eosinophilia.Image will show interstial thickening, diffused nodular mottling.

Management of Filariasis 313 Drugs effective against filarial parasites Diethyl Carbomazine citrate (DEC) Ivermectin Albendazole Couramin compound Corticosteroids surgical Treatment of microfilaraemic patients may prevent chronic obstructive disease and may be repeated every 6 months till mf and/or symptoms disappears.

Diethyl Carbomazine Citrate ( Hetrazan , Banocide , Notezine ) 314 Mode of action: DEC do not have direct action of parasite but mediate through host immune system. Very effective against mf ( Microfilariacidal ) Lowers mf level even in single dose Effective against adult worms in 50% of patients in sensitive cases. Dose: 6mg/Kg/12 days Recent dosage: 6mg/Kg single dose

DEC…. 315 Adverse reactions of DEC are mostly due to the rapid destruction of mf which is characterised by fever, nausea, myalgia , sore throat, cough, headache. Drug of choice in the treatment of TPE.

Ivermectin 316 Mode of action: Directly acts on mf and no action on adults. Very effective against mf ( Microfilariacidal ) Lowers mf level even in single dose of 200µg – 400µg/Kg body weight No action on TPE Drug of choice in Co-endemic areas of Onchocerciasis with LF. Adverse reactions are lesser but similar to that of DEC Microfilariae reappears faster than DEC

Albendazole 317 This antihelmenthic kills adult worms No action on microfilariae Dose: 400mg/twice day /2 weeks With combination of DEC & Ivermectin , it enhances the action of the drugs. It induces severe adverse reactions in hydrocele cases due to the death of adult worms.

Prevention and controlof Filariasis 318 public education vector control mass or selective Rx

LEISHMANIASIS 319 A polymorphic protozoan disease of the skin and mucous membrane or a chronic systemic disease caused by a number of species of the genus leishmania . Infectious agents For cutaneous and mucosal Leishmaniasis Leishmania tropica & Leishmania donovani * Leishmania major and Leishmania infantum * Leishmania aethiopica *

320 For visceral Leishmaniasis ( kalaazar ) Leishmania donovani . * Leishmania infantum . * Leishmania tropica . * and Leishmania chagasi . * *Common agents in Ethiopia. SYNONYMS : kala azar , black fever, sandfly disease, Dum-Dum fever and espundia .

Epidemiology 321 Occurrence - It occurs in Pakistan, India and recently China, the Middle East including Iran and Afghanistan, southern regions of the former Soviet Union, sub-Saharan Africa, Sudan, the highlands of Ethiopia, Kenya and Namibia. Urban populations including children may be at risk.

322 In the developed world, the disease is restricted to occupational groups, such as those involved in work in forest areas; to those whose homes are in or next to a forest and to visitors to such areas from non-endemic countries. It is common where dog populations are high, generally more common in rural than urban areas.

323 Reservoirs- locally variable; include human beings, wild carnivores and domestic dogs. Mode of transmission- Transmission is through the bite of the female phlebotomine ( sand flies ). From person to person, by blood transfusion, and sexual contact has been reported, but rare. Incubation period- at least a week; up to many months.

324 Period of communicability- Infectious to sand flies as long as parasites remain in lesion, in untreated cases, usually a few months to 2 years. Eventual spontaneous healing occurs in most cases. Susceptibility and resistance- Susceptibility is probably general. Life-long immunity may be present after lesion due to L. tropica or L. major but may not protect against other leishmanial species.

Life cycle and MT 325 Transmission by the bite of female phlebotomies sand flies (p. orentalies and p. martini) Promastigote injected through skin when sand fly takes blood In human host promastigote takes up by macrophage became amastigote

Life cycle ( cont,d ) 326 Multiply in reticulo -endothelial cell (VL) or skin macrophage (CL and MCL) Amastigote ingested by sand fly Amastigote became promastigote within a week Promastigote multiply, migrate head and mouth part of fly.

LIFE CYCLE

Clinical manifestation 328 cutaneous -chronic painless nodule -ulcer, circular,& indurated muco - cutaneous -mucosal lesion on the nose, mouth and pharynx Visceral - fever, weight loss - hepatomegally , spleenomegally -enlarged lymph nodes -darkening of skin( black disease) -anemia, hemorrhage - malnutrition progressive emaciation and weakness.

Diagnosis 329 Clinical features Serological test(DAT)-anti body detection test PCR (polymerase chain reaction test)-Ag detection Biopsy ( spleen, liver, LNs, bone marrow) DDx - malaria -Typhoid fever - Schistosomiasis -Brucellosis

330 Treatment Sodium stibogluconate , 20 mg/Kg/day given IV OR IM in a single dose for 28 consecutive days. Therapy should be repeated using the same dose for another 40 to 60 days in patients with relapse or incomplete response. For Cutaneous Leishmaniasis : Sodium stibogluconate , given intramuscularly IM OR IV QD for 10 days.

331 Prevention and control 1. The avoidance of outdoor activities. 2. The use of mechanical barriers such as screens and bed nets. 3. Wearing of protective clothing. 4. Application of insect repellent. 5. Treatment of cases. 6. Vector control and elimination of reservoir host (e.g. domestic dogs).

Prevention and control…. 332 Vector control -spraying -repellents -limit outdoor activities during night -eliminate breeding site -mechanical barriers( e.g. bed nets, screen -protective clothing Environmental management

African Trypanosomiasis 333 A systemic disease caused by protozoa characterized by fever followed by general weakness and cerebral involvement leading to death. Infectious agent The commonest agents are: T. Brucei rhodesiense T. Brucei gambiense Other species which are less important are; T. Cruzi , which causes American Trypanosoniasis Vectors for all species are tsetse flies of Genus Glossina .

Epidemiology 334 Occurrence-The trypanosomes that cause sleeping sickness are found only in Africa. 20,000 new cases are reported each year. This number surely under-estimates the true incidence. T. brucei gambiense occurs and is widely distributed in the tropical rainforests of Central and West Africa.

335 Gambiense trypanosomes are primarily a problem in rural population; tourists rarely become infected. The principal reservoir of T.B rhodesiense in savanna and woodland areas of Central and East Africa are Trypotolerant antelope species. Humans acquire T.B. rhodesiense infection only incidentally while working in areas where infected vectors are present.

336 T. ganebie has no animal reservoir. However, T. rhodesiense causes the more severe trypanosomiasis without sleeping sickness. In Ethiopia, the distribution of Trypanosomiasis is mostly found in Jinca , Afar, Setitu Humera , Konso , Moyale , Woito , and Dilla .

337 Reservoir- for T. brucie gambiense it is only humans. For T. brucie rhodesiense the reservoir is dog, cattle, fox, wolf and human beings. Mode of transmission- by the bite of infective Glossina Tsetse fly during blood meal. Congenital transmission can occur in humans. Direct mechanical transmission is possible by blood on the proboscis of Glossina and other man-biting insects, such as houseflies or in laboratory accidents

338 Incubation period- T. brucei rhodensiense : 3 days to few weeks. T. brucei gambiense : several months up to one year. Period of communicability- The disease is transmitted as long as the parasite is present in the blood of infected person or animal and infected Tsetse fly. Susceptibility and resistance- All persons are equally susceptible for the disease.

339 Clinical Manifestation Stage I (Signs & symptoms) 1. Painful trypanosoma chancre 2. Hematogenous and lymphatic dissemination 3. High body temperature 4. Lymphadenopathy discrete 5. Winter bottom’s sign (classic), painless enlargement of lymph node

340 6.Malaise 7. Headache 8. Weight loss 9. Edema 10. Hepatomegally and 11. Tachycardia

341 Stage II 1. Abnormality in CSF 2. Day time somnolence 3. Tremors 4. Parkinson’s disease may appear 5. Hypertonia 6. Congestive heart failure 7. CNS disease develops 8. Coma and death

342 Diagnosis Wet blood smear Thick blood smear Serological test CSF analysis Blood film Bone marrow biopsy

343 Treatment 1. Pentamidine or 2. Etlornithine or 3. Helarsupron or 4. Trypansamide These are drugs to be used for treatment of different stages. For stage I (Normal CSF) – T.b . gambie treated with Suramin or Eflornithine or Pentamidine For stage II : Trypansamide

344 Prevention and control 1. Public education on personal measures to protect against insect bite. 2. Eradication of vectors. 3. Drug treatment of infected humans. 4. Avoiding areas to be known by harboring infected insects. 5. By wearing protective cloth and by using insect repellents.

345 6 .Reducing tsetse fly number by Identifying and studying the breeding habits of local vector Selectively clearing the bush and wooden areas especially around game reservoirs, water holes, bridges and along rivers bank Using and maintaining insecticide impregnated tsetse fly traps. 7. Spraying vehicles with insecticide as they enter and leave tsetse fly infested areas 8. Prohibit blood donation from those who have visited or lived in endemic areas.

Yellow fever 346 An acute infectious viral disease of short duration and varying Severity. Yellow fever virus

Relapsing Fever ( RF ) 347 An acute infectious bacterial disease characterized by alternating febrile periods (recurrent pyrexial attacks). Systemic spirochete infection characterized by alternative febrile period i.e. pt febrile 2-9 days and became a febrile for 2-5 days & may be 1-10 relapse(recurrent pyrexia attack)

348 Infectious agent : Genus spirochete Borelli B. recurrentis (louse-born)-epidemic type B. dottoni (tick-born)-endemic type

Cont,d .. 349 Epidemiology : Common in Asia, S. America Central and East Africa(Ethiopia, Rwanda, Sudan, Burundi...) Common in – - overcrowding, -Unhygienic condition -Migrants, refugee camps, -High land areas

Cont,d 350 Reservoir -human for (B.rec) -wild rodent for ( B.dottoni ) MT : vector-borne. Acquired by crushing an infected louse so that it contaminates the bite wound or an abrasion of the skin. during crushing of an infected louse( stercorarial )

Clinical Manifestation 351 CM : 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.

352 IP : 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) Susceptibility and resistance- Susceptibility is general. Duration and degree of immunity after clinical attack are unknown; repeated infection may occur.

353 Dx : Clinical and epidemiological grounds Giemsa or Wright stain (blood film) Dark field microscopy of fresh blood.

T reatment Treatment 354 Admit the patient. Open vein (i.e. start iv-line) 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.

Nursing care 355 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 356 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.

Rickettsial disease 357 Disease transmitted by Arthropods (tick, louse, mite, flea..) The major reckettsias include R. prowazeki -cause epidemic (louse-born) typhus ( importance public h/problem) R. typhi -- endemic typhus R. tsutsugamushi --cause scrub typhus R. recketti --Rocky Mountain spotted fever R. conori --tick typhus

Cont,d 358 Epidemiology : common in-poor socio-economic -cold areas -war, famine, -Africa, S.America, Asia MT : vector- body louse (Pediculus humanis) - stercorarial transmission)

Cont,d 359 Pathogenesis : reckettesial invade the endothelial cells ↓ Vasculitis ↓ Impair vascular integrity ↓ Increase permeability ↓ Oedema, hypovolemia, hypotension Reservoir: human

Clinical manfestation 360 sudden onset of fever, headache, chills, rigor, malaise, Maculo-papular/peteacheal rash on the palms ,soles, trunk. Tender lymphadenopathy IP: 1-2 weeks Complication: CNS (aseptic meneigitis, encephalitis, optic neuritis, deafness.. KIDENY( renal failer) Heart ( myocarditis)

Cont,d 361 Dx : characteristics of rash Serologic ( weil-flix test,OX-19) PCR, culture Rx : CAF, TTC, Doxycycline , Ciprofloxacin .

Prevention and control 362 Improve living condition Steaming and delousing clothes Personal hygiene ( bathing, washing clothes.. Rx of cases Isolation, quarantine. Chemoprophylaxis for contacts Reporting, notification to WHO

Discussion What is indirect MT? what is air born disease? What air born disease do you know? 363

Air born disease Tuberculosis Infectious agent: bacilli -Koch’s bacilli (M.Tbc complex) -strictly aerobic bacteria -multiply in pulmonary tissue particularly at the apex, where oxygen tension is greater Other mycobacterium-M. africanum( seen in western Africa) -M. bovis( <1%, reservoir is cattle) -M. canetti.. Transmission : via air born, during coughing, sneezing, speaking produce tiny droplet→ dry out, suspended in the air for several hours infectious droplet are inhaled 364

Factor contributing for better transmission dark area, closeness of contact poor ventilation duration of exposure, bacteriological status of pt N.B. among these infected in Tbc bacilli, approximately 10% will develop active disease during their life 365

Evolution of the bacilli 1.Primary infection( 90% of cases) multiply slowly in the terminal alveoli of lungs (Ghon focus) corresponding LNs(hilar LAP) Usually asymptomatic, hypersensitivity reaction in rare cases For the other 10% of individuals, development and multiplication of bacilli continues primary in the lungs and pleural and then spreads and provoke disseminated disease 2. Post primary infection –occurs after months or years following primary infection usually due to reactivation of the dormant bacilli as the result of weakening of immune system e.g. HIV 366

Risk of developing active Tbc after primary infection Depends on host immune system -age( child 5x higher risk than older) -Disease condition ( HIV 170x, DM 113x.. -mal-nutrition , pregnancy -alcohol, drugs, tobacco…. Prognosis: (after 5 year without Rx) 50-60%...will die 20-25 %...cured spontaneously 20-25% ..chronically ill With Rx: CFR= < 5% 367

Modifying factor of Tbc epidemiology socio-economic status BCG vaccine HIV infection chemotherapy 368

Cont,d IP : 4-16 weeks after infection CM : PTbc (accounts 80%) Cough > two weeks Chest pain Loss of weight and appetite Fatigue ,moderate fever, night sweating EPTbc (accounts 20% ) Common EPTC-Tbc lymphadeniti, bone and joints, spondylitis , ascitis, GUT, pericarditis, meningitis , disseminated N.B : CM of EPTbc depends of site of involvement 369

Cont,d Dx : sputum for AFB Culture X-ray for smear negative, children, & EPTbc Tuberculin skin test ( PPD, mantoux,s test) Biopsy Blood ( ESR, CBC.) In children -X- ray -Paediatric score test 370

Rx Rx category Category ONE for new cases 6 month regimen- 2SRHZ\4RH or 2ERHZ\4RH 8 month regimen- 2SRHZ\6EH or 2ERHZ\6EH Category TWO for relapse, return after default, or other 2 SHRZE\1ERHZ\5RHE S= strepomycin R= Rifampicin H= isonized(INH) Z= pyrazinamide E= ethambuton 371

Rx (cont,d) Second line drugs (in case of resistance and sever side effect) Capreomycin(CM) Kanamycin(KM) Amikacin(AMK) Ethionamid(Etho) Fluooquinolons(FQ)-ofloxacin, Levofloxacin, Cyclocerin, PAS.. 372

Prevention and control Improve socio-economic status ( living condition, nutrition… Avoid over crowding Isolation Early Dx and Rx Screening 373

Meningitis An inflammation of the meninges Cause : 1.bacteria- (pyogenic meningitis) -E.coli -group B streptococcus in neonate -listeria monocytogens - Proteous, pseudomonas -N.meningitis - H. Influnzea in under 5 children - S. Pnuemonea - N.meningitits in adults S. Pnuemonea 374

Cont.d… 2. Viruses called aseptic meningitis Arbo virus Entro virus Mumps, HSV-2, HIV.. 3. Mycobacterium ( M.Tbc) 4. Fungal , Protozoan … 375

Epidemiology N. Meningitides (meningococcal) –gm-ve, diplococcic, intracellular most epidemic serotype: (A,B,C,D,W,X,Y,Z) Occurs in meningial belt Occurs in dry season( Dec-Feb Reservoir: human IP: 2-10 days 376

Cont,d… MT : contact of large droplet with mucus membrane via direct projection during sneezing, speaking... ↓ Colonization of naso-pharnyx mucosa ↓ Invasion of meninges via haematogenous spread ↓ Inflammation of sub-arachnoids space ↓ CM : sudden onset of fever, headache N/V, photophobia Neck pain, rash.. 377

Cont,d Dx : ▼Clinical and epidemiological ground ▼PE-neck stiffness + kerning sign + brudiniski sign ▼Laboratory-CSF analysis for colour, glucose, protien.. ▼Serological test-for viral causes Compli : deafness, sub-dural haematoma Blindness, cerebral abscess Cranial palsy, arthritis Hydrocephalus, pericarditis….. 378

Cont,d Rx : Early Dx and Rx( life treating and emergency) Lumbar puncture (LP) for all cases Empirical antibiotics ( Cry.pcn,CAF) then based on culture and sensitivity Prevention Public education Avoiding over crowding Vaccination (for group A,C.W-135,Y) Chemoprophylaxis for contacts ( Rifampicin, Ciprofloxacin..) Isolation Disinfection Routine and timely surveillance 379

Leprosy (Hansen's disease) Chronic bacterial disease of the skin, and nerves of hands, foots sometimes the linings of the nose. Infectious agent : Mycobacterium leprea Epidemiology : common in Asia, Africa, S. America Common in temperate, tropical, sub-tropical Approximately 830,000cases world wide MT : not clear but…. Prolonged close contact Air bore through nasal discharge IP : 4-8 380

Cont,d Form : 1. Tubercliod Type (TT) –mild form 2. Borderline Leprosy (BL)-moderate 3. Lepromatous Leprosy (LL)-sever form affect peripheral nerves of hands, foots and lining of mucus membrane of nose( stuff nose) S/S : skin lesion (hypo pigmented) Loss of sensation, numbness, muscle weakness Tender peripheral nerves Complication ; peripheral nerve damage Deformity, disability 381

Cont,d Dx : clinical feature Skin scrapping for AFB Rx ; Multi Drug Therapy ( MDT )-Dapson -Rifampicin -Clofazimine Prevention Avoiding close physical contact Early Dx and Rx Screening for contacts 382

Assignment Write short note on poliomylitis , shistosomiasis, gina worm, pulmonary tuberclosis NB: ( Definition,infection agent,life cycle,sign and symptom,complication , Management(treatment),prevention)

6/5/2023 cdc introduction 384 THANK YOU FOR YOUR ATTENTION !!!

ORAL-FECAL TRANSMITTED DISEASES.......pptx

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