COMMUNICABLE DISEASE NURSING (Part II: Diseases)

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Communicable Disease Nursing

I. EPI DISEASES DISEASE 1. Tuberculosis Other names: Koch’s Disease Consumption Phthisis Weak lungs

CAUSATIVE AGENT Mycobacterium tuberculosis TB bacillus Koch’s bacillus Mycobacterium bovis (rod-shaped)

MODE OF TRANSMISSION Airborne-droplet Direct invasion through mucous membranes and breaks in the skin (very rare)

Most hazardous period for development of clinical Incubation period : 4 – 6 weeks disease is the first 6-12 months after infection Highest risk of developing disease is children under 3years old

PATHOGNOMONIC SIGN 1. Usually asymptomatic 2. Low-grade afternoon fever 3. Night sweating 4. Loss of appetite 5. Weight loss 6. Easy fatigability – due to increased oxygen demand 7. Temporary amenorrhea 8. Productive dry cough 9. Hemoptysis

TREATMENT: SCC/Short Course Chemotherapy, Direct –observed treatment short course/DOTS; Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S) CATEGORY 1: 6 months SCC Indications: > new (+) smear > (-) smear PTB with extensive parenchymal lesions on CXR > Extrapulmonary TB > severe concominant HIV disease Intensive Phase: 2 months R&I : 1 tab each; P&E 2 tabs each Continuation Phase: 4 months R&I : 1 tab each

CATEGORY 2: 8 months SCC Indications: > treatment failure > relapse > return after default Intensive Phase:3 mos R&I 1 tab each; P&E 2 tabs each Streptomycin – 1 vial/day IM for first 2 months = 56 vials (if given for > 2mos can cause nephrotoxicity Continuation Phase: 5 months R&I : 1 tab each E : 2 tabs

CATEGORY 3: 6 months SCC Indications: > new (-) smear PTB with minimal lesions on CXR Same meds with Category 1 Intensive Phase: 2 months R&I 1 tab each; P&E 2 tabs each Continuation Phase: 4 months R&I 1 tab each CATEGORY 4: Chronic (*Referral needed)

SIDE EFFECTS: Rifampicin • body fluid discoloration • hepatotoxic • permanent discoloration of contact lenses Isoniazid • Peripheral neuropathy (Give Vit B6/Pyridoxine) Pyrazinamide • hyperuricemia /gouty arthritis (increase fluid intake)

MANAGEMENT/TREATMENT

PREVENTION

Diagnostic test: • Sputum examination or the Acid-fast bacilli (AFB) / sputum microscopy 1. Confirmatory test 2. Early morning sputum about 3-5 cc 3. Maintain NPO before collecting sputum 4. Give oral care after the procedure 5. Label and immediately send to laboratory 6. If the time of the collection of the sputum is unknown, discard • Chest X-ray is used to: 1. Determine the clinical activity of TB, whether it is inactive (in control) or active (ongoing) 2. To determine the size of the lesion: a. Minimal – very small b. Moderately advance – lesion is < 4 cm c. Far advance – lesion is > 4 cm • Tuberculin Test – purpose is to determine the history of exposure to tuberculosis Other names: Mantoux Test – used for single screening, result interpreted after 72 hours Tine test – used for mass screening read after 48 hours Interpretation: 0 - 4 mm induration – not significant 5 mm or more – significant in individuals who are considered at risk; positive for patients who are HIV-positive or have HIV risk factors and are of unknown HIV status, those who are close contacts with an active case, and those who have chest x-ray results consistent with tuberculosis. 10 mm or greater – significant in individuals who have normal or mildly impaired immunity

• Respiratory precautions • Cover the mouth and nose when sneezing to avoid mode of transmission • Give BCG BCG is ideally given at birth, then at school entrance. If given at 12 months, perform tuberculin testing (PPD), give BCG if negative. • Improve social conditions SIDE EFFECTS: Ethambutol • Optic neuritis • Blurring of vision (Not to be givento children below 6 y.o. due to inability to complain blurring of vision) • Inability to recognize green from blue Streptomycin • Damage to 8th CN • Ototoxic • Tinnitus • nephrotoxic

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NATIONAL TB CONTROL PROGRAM: Vision: A country where TB is no longer a public health problem Mission: Ensure that TB DOTS Services are available, accessible, and affordable to the communities in collaboration with LGUs and others Goal: To reduce prevalence and mortality from TB by half by the year 2015 (Millennium Development Goal) Targets: 1. Cure at least 85% of the sputum smear (+) patients discovered 2. Detect at least 70% new sputum smear (+) TB cases Objectives: 1. Improve access to and quality of services 2. Enhance stakeholder’s health-seeking behavior 3. Increase and sustain support for TB control activities 4. Strengthen management of TB control activities at all levels KEY POLICIES: *Case finding: - DSSM shall be the primary diagnostic tool in NTP case finding - No TB Dx shall be made based on CXR results alone - All TB symptomatic shall be asked to undergo DSSM before treatment - Only contraindication for sputum collection is hemoptysis - PTB symptomatic shall be asked to undergo other tests (CXR and culture), only after three sputum specimens yield negative results in DSSM - Only trained med techs / microscopists shall perform DSSM - Passive case finding shall be implemented in all health stations

Communicable Disease Nursing

s MANAGEMENT OF CHILDREN WITH TUBERCULOSIS - for TB symptomatic children *a TB symptomatic child with either known or Prevention: BCG immunization to all infants (EPI) unknown exposure to a TB case shall be referred for tuberculin testing Casefinding: * (+) contact but (-) tuberculin test and unknown - cases of TB in children are reported and identified in 2 contact but (+) tuberculin test shall be referred for instances: (a) patient was screened and was found symptomatic CXR examination of TB after consultaion (b) patient was reported to have been *(-) CXR, repeat tuberculin test after 3 months exposed to an adult TB patient * INH chemoprophylaxis for three months shall be - ALL TB symptomatic children 0-9 y.o, EXCEPT sputum given to children less than 5y.o. with (-) CXR; after positive child shall be subjected to Tuberculin testing (Note: which tuberculin test shall be repeated Only a trained PHN or main health center midwife shall do tuberculin testing and reading which shall be conducted once a Treatment (Child with TB): week either on a Monday or Tuesday. Ten children shall be Short course regimen gathered for testing to avoid wastage. PULMONARY TB Intensive: 3 anti-TB drugs (R.I.P.) for 2 months - Criteria to be TB symptomatic (any three of the following:) Continuation: 2 anti-TB drugs (R&I) for 4 months * cough/wheezing of 2 weeks or more * unexplained fever of 2 weeks or more EXTRA-PULMONARY TB * loss of appetite/loss of weight/failure to gain weight/weight Intensive: 4 anti-TB drugs (RIP&E/S) for 2 months faltering Continuation: 2 anti-TB drugs (R&I) for 10 months * failure to respond to 2 weeks of appropriate antibiotic therapy for lower respiratory tract infection *Treatment: Domiciliary treatment – preferred mode of care * failure to regain previous state of health 2 weeks after a viral DSSM – basis for treatment of all TB cases infection or exanthem (e.g. measles) PERIOD OF COMMUNICABILITY OF *Hospitalization is recommended: massive hemoptysis, pleural effusion, TUBERCULOSIS: military TB, TB meningitis, TB pneumonia, & surgery is needed or with -Conditions confirming TB diagnosis (any 3 of the following:)  as long as bacillus is contained in the complications * (+) history of exposure to an adult/adolescent TB case sputum *All patients undergoing treatment shall be supervised * (+) signs and symptoms suggestive of TB  Primary complex in children is NOT *National & LGUs shall ensure provision of drugs to all smear (+) TB cases * (+) tuberculin test contagious *Quality of fixed-dose combination (FDC) must be ensured * abnormal CXR suggestive of TB  Good compliance to regimen renders *Treatment shall be based on recommended category of treatment regimen * Lab findings suggestive or indicative of TB person not contagious 2-4 weeks after initiation of treatment DOTS Strategy – internationally-recommended TB control strategy - for children with exposure to TB Five Elements of DOTS: (RUSAS) Recording & reporting system enabling outcome assessment of all patients * a child w/ exposure to a TB registered adult patient shall undergo physical exam and tuberculin testing Uninterrupted supply of quality-assured drugs * a child with productive cough shall be referred for sputum Standardized SCC for all TB cases exam, for (+) sputum smear child, start treatment immediately Access to quality-assured sputum microscopy * TB asymptomatic but (+) tuberculin test and TB symptomatic Sustained political commitment but (-) tuberculin test shall be referred for CXR examination

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2. Diphtheria Types: > nasal > pharyngeal – most common > laryngeal – most fatal due to proximity to epiglottis

3. Pertussis Whooping cough Tusperina No day cough

Corynebacterium diphtheria Klebbs-loffler

***Diphtheria transmission is increased in hospitals, households, schools, and other crowded areas. Bordetella pertussis Hemophilus pertussis Bordet-gengou bacillus Pertussis bacillus

Communicable Disease Nursing

Droplet especially secretions from mucous membranes of the nose and nasopharynx and from skin and other lesions Milk has served as a vehicle Incubation Period: 2 – 5 days Droplet especially from laryngeal and bronchial secretions Incubation Period: 7 – 10 days but not exceeding 21 days

Pseudomembrane – mycelia of the oral mucosa causing formation of white membrane on the oropharynx Bull neck Dysphagia Dyspnea

Complication: MYOCARDITIS (Encourage bed rest) Catarrhal period: 7 days paroxysmal cough followed by continuous nonstop accompanied by vomiting Complication: abdominal hernia

Incidence: highest under 7 years of age Mortality: highest among infants ( Hepatitis B Immunoglobulin Diet: high in carbohydrates

Hepatitis A – infectious hepatitis; oral-fecal Hepatitis B – serum hepatitis; blood and body fluids Hepatitis C – non-A non-B, post-transfusion hepatitis; blood and body fluids Hepatitis D – Delta hepatitis or dormant hepatitis; blood and body fluids; needs past history of infection to Hepatitis B Hepatitis E – oral-fecal

Measles vaccine Disinfection of soiled articles Isolation of cased from diagnosis until about 5-7 days after onset of rash

-Hepatitis B immunization -Wear protected clothing -Hand washing -Observe safe-sex -Sterilize instruments used in minor surgical-dental procedures -Screening of blood products for transfusion

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Communicable Disease Nursing

II. DISEASES TRANSMITTED THROUGH FOOD AND WATER DISEASE 1. Cholera Other names: El tor

CAUSATIVE AGENT Vibrio cholera Vibrio coma Ogawa and Inaba bacteria

MODE OF TRANSMISSION Fecal-oral route

PATHOGNOMONIC SIGN Rice watery stool

5 Fs

Period of Communicability: 7-14 days after onset, occasionally 2-3 months

Incubation Period: Few hours to 5 days; usually 3 days 2. Amoebic Dysentery

Entamoeba histolytica

Fecal-oral route

Protozoan (slipper-shaped body) 3. Shigellosis

Shigella bacillus

Fecal-oral route

Other names: Bacillary dysentery

Sh-dysenterae – most infectious Sh-flesneri – common in the Philippines Sh-connei Sh-boydii

5 Fs: Finger, Foods, Feces, Flies, Fomites

4. Typhoid fever

Salmonella typhosa (plural, typhi)

Incubation Period: 1 day, usually less than 4 days Fecal-oral route 5 Fs

5. Hepatitis A Other names: Infectious

Hepatitis A Virus

Incubation Period: Usual range 1 to 3 weeks, average 2 weeks Fecal-oral route 5 Fs

• Abdominal cramping • Bloody mucoid stool • Tenesmus - feeling of incomplete defecation (Wikipedia) • Abdominal cramping • Bloody mucoid stool • Tenesmus - feeling of incomplete defecation (Wikipedia)

• Rose Spots in the abdomen – due to bleeding caused by perforation of the Peyer’s patches

MANAGEMENT/TREATMENT Diagnostic Test: Stool culture Treatment: Oral rehydration solution (ORESOL) IVF Drug-of-Choice: tetracycline (use straw; can cause staining of teeth). Oral tetracycline should be administered with meals or after milk. Treatment: Metronidazole (Flagyl) * Avoid alcohol because of its Antabuse effect can cause vomiting Drug-of-Choice: Co-trimoxazole

PREVENTION Proper handwashing Proper food and water sanitation Immunization of Chole-vac

Proper handwashing Proper food and water sanitation

Diet: Low fiber, plenty of fluids, easily digestible foods

Proper handwashing Proper food and water sanitation Fly control

Diagnostic Test: Typhi dot – confirmatory test; specimen is feces Widal’s test – agglutination of the patient’s serum

Proper handwashing Proper food and water sanitation

Drug-of-Choice: Chloramphenicol

• Ladderlike fever • Fever • Anorexia (early sign) • Headache • Jaundice (late sign)

Prophylaxis: “IM” injection of gamma globulin Hepatitis A vaccine Hepatitis immunoglobulin Avoid alcohol

Proper handwashing Proper food and water sanitation Proper disposal of urine

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Hepatitis / Epidemic Hepatitis / Catarrhal Jaundice 6. Paralytic Shellfish Poisoning (PSP I Red tide poisoning)

Communicable Disease Nursing

Incubation Period: 15-50 days, depending on dose, average 20-30 days Dinoflagellates Phytoplankton

Ingestion of raw of inadequately cooked seafood usually bivalve mollusks during red tide season Incubation Period: 30 minutes to several hours after ingestion

• Clay-colored stool • Lymphadenopathy

Complete bed rest – to reduce the breakdown of fats for metabolic needs of liver Low-fat diet; increase carbohydrates (high in sugar)

In convalescent period, patient may have difficulty with maintaining a sense of well-being. Treatment: • Numbness of face 1. No definite treatment especially around the 2. Induce vomiting mouth 3. Drink pure coconut milk – weakens the • Vomiting and dizziness toxic effect • Headache 4. Sodium bicarbonate solution (25 grams in ½ • Tingling glass of water) sensation/paresthesia and Advised only in the early stage of illness eventful paralysis of because paralysis can lead to aspiration hands NOTE: Persons who survived the first 12 hours after • Floating sensation and ingestion have a greater chance of survival. weakness • Rapid pulse • Dysphonia • Dysphagia • Total muscle paralysis leading to respiratory arrest and death

and feces Separate and proper cleaning of articles used by patient 1. Avoid eating shellfish such as tahong, talaba, halaan, kabiya, abaniko during red tide season 2. Don’t mix vinegar to shellfish it will increase toxic effect 15 times greater

ROBERT C. REÑA, BSN Death from diarrhea is usually due to dehydration. Food recall is the basis for the diagnosis of food poisoning.

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Communicable Disease Nursing

III. SEXUALLY TRANSMITTED DISEASES DISEASE 1. Syphilis Other names: Sy Bad Blood The pox Lues venereal Morbus gallicus

CAUSATIVE AGENT Treponema pallidum (a spirochete) Incubation Period: 10 to 90 days (3 months); average of 21 days

MODE OF TRANSMISSION Direct contact Transplacental (after 16th week AOG) Through blood transfusion Indirect contact with contaminated articles

PATHOGNOMONIC SIGN Primary stage (4-6 weeks): painless chancre at site of entry of germ with serous exudates Tertiary stage (one to 35 years) : Gumma, syphilitic endocarditis and meningitis

Other names: GC, Clap, Drip, Stain, Gleet, Flores Blancas

Primary and secondary sores will go even without treatment but the germs continue to spread throughout the body. Latent syphilis may continue 5 to 20+ years with NO symptoms, but the person is NO longer infectious to other people. A pregnant mother can transmit the disease to her unborn child (congenital syphilis). Neiserria gonorrheae Direct contact – Thick purulent yellowish genitals, anus, discharge mouth Burning sensation upon urination / dysuria Incubation Period: 2 – 10 days

3. Trichomoniasis

Trichomonas vaginalis

2. Gonorrhea

Other names: Vaginitis Trich

4. Chlamydia

Direct contact Incubation Period: 4 – 20 days; average of 7 days

Chlamydia trachomatis (a rickettsia)

Direct contact

Females: white or greenish-yellow odorous discharge vaginal itching and soreness painful urination Males: Slight itching of penis Painful urination Clear discharge from penis Females: Asymptomatic

MANAGEMENT/TREATMENT Diagnostic test: Dark field illumination test Fluorescent treponemal antibody absorption test – most reliable and sensitive diagnostic test for Syphilis; serologic test for syphilis which involves antibody detection by microscopic flocculation of the antigen suspension VDRL slide test, CSF analysis, Kalm test, Wasseman test

PREVENTION Abstinence Be faithful Condom Secondary syphilis (6-8 weeks: generalized rashes, generalized tender discrete lymphadenopathy, mucus patches, flu-like symptoms, condylomata, patchy alopecia

Treatment: Drug of Choice: Penicillin (Tetracycline if resistant to Penicillin)

Latent stage (one to two to 50 years): non-infectious

Diagnostic test: Culture of urethral and cervical smear Gram staining

Abstinence, Be faithful Condom

Treatment: Drug of Choice: Penicillin

Diagnostic Test: Culture

Prevention of gonococcal ophthalmia is done through the prophylactic use of ophthalmic preparations with erythromycin or tetracycline Abstinence Be faithful Condom

Treatment: Drug of Choice: Metronidazole (Flagyl)

Personal Hygiene

Diagnostic Test: Culture

Abstinence Be faithful

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Communicable Disease Nursing

Incubation Period: 2 to 3 weeks for males; usually no symptoms for females

5. Candidiasis

Candida albicans

Direct contact

Other names: Moniliasis Candidosis

6. Acquired immune deficiency syndrome (AIDS)

Retrovirus (Human T-cell lymphotrophic virus 3 or HTLV 3)

Direct contact Blood and body fluids Transplacental

Attacks the T4 cells: Thelper cells; Tlymphocytes, and CD4 lymphocytes

Incubation period: 3-6 months to 8-10 years

The major route of HIV transmission to adolescent is SEXUAL TRANSMISSION. French kissing brings low risk of HIV transmission.

Variable. Although the time from infection to the development of detectable antibodies is generally 1-3 months, the time from HIV infection to diagnosis of AIDS has an observed range of less than 1 year to

Dyspareunia Fishy vaginal discharge Males: Burning sensation during urination Burning and itching of urethral opening (urethritis) White, cheese-like vaginal discharges Curd like secretions

1. Window Phase a. initial infection b. lasts 4 weeks to 6 months c. not observed by present laboratory test (test should be repeated after 6 months) 2. Acute Primary HIV Infection a. short, symptomatic period b. flu-like symptoms c. ideal time to undergo screening test (ELISA) 3. Asymptomatic HIV Infection a. with antibodies against HIV but not protective

Condom Treatment: Drug of Choice: Tetracycline

Diagnostic Test: Culture Gram staining Treatment: Nystatin for oral thrush Cotrimazole, fluconazole for mucous membrane and vaginal infection Fluconazole or amphotericin for systemic infection Diagnostic tests: Enzyme-Linked Immuno-Sorbent Assay (ELISA) - presumptive test Western Blot – confirmatory Treatment: 1. Treatment of opportunistic infection 2. Nutritional rehabilitation 3. AZT (Zidovudine) – retards the replication of retrovirus; must be taken exactly as ordered 4. PK 1614 – mutagen Major signs of Pediatric AIDS:  Chronic diarrhea > 1 month  Prolonged fever > 1 month  Weight loss or abnormally slow growth Breastmilk is important in preventing intercurrent infection in HIV infected infants and children.

Abstinence Be faithful Condom

Abstinence Be faithful Condom Sterilize needles, syringes, and instruments used for cutting operations Proper screening of blood donors Rigid examination of blood and other blood products Avoid oral, anal contact and swallowing of semen Avoid promiscuous sexual contact Avoid sharing of

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Communicable Disease Nursing

15 years or longer. (PHN Book)

b. lasts for 1-20 years depending upon factors 4. ARC (AIDS Related Complex) a. a group of symptoms indicating the disease is likely to progress to AIDS b. fever of unknown origin c. night sweats d. chronic intermittent diarrhea e. lymphadenopathy f. 10% body weight loss 5. AIDS a. manifestation of severe immunosuppression b. CD4 Count: 38 0C) Chills Malaise Myalgia Headache Infectivity is none to low Respiratory Phase: Within 2-7 days, dry nonproductive cough progressing to respiratory distress

MANAGEMENT/TREATMENT

PREVENTION

Respiratory isolation within 24 hours

Universal precaution

Drug-of-Choice: Penicillin

Chemoprophylaxis with Rifampicin to protect exposed individual from developing the infection Proper hand washing

No specific treatment PREVENTIVE MEASURES and CONTROL 1. Establishment of triage 2. Identification of patient 3. Isolation of suspected probable case 4. Tracing and monitoring of close contact 5. Barrier nursing technique for suspected and probable case

Utilize personal protective equipment (N95 mask) Handwashing Universal Precaution The patient wears mask Isolation

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3. Bird Flu

Influenza Virus H5N1

Other Name: Avian Flu

Influenza Virus A H1N1

Other Name: Swine Flu

This new virus was first detected in people in April 2009 in the United States.

June 11, 2009 - The WHO raises its Pandemic Alert Level to Phase 6, citing significant transmission of the virus.

Contact with infected birds Incubation Period: 3 days, ranges from 2 – 4 days

4. Influenza A (H1N1)

May 21, 2009 – first confirmed case in the Philippines

Communicable Disease Nursing

Influenza A (H1N1) is fatal to humans

Exposure to droplets from the cough and sneeze of the infected person Influenza A (H1N1) is not transmitted by eating thoroughly cooked pork. The virus is killed by cooking temperatures of 160 F/70 C. Incubation Period: 7 to 10 days

Fever Body weakness and body malaise Cough Sore throat Dyspnea Sore eyes

- similar to the symptoms

of regular flu such as • Fever • Headache • Fatigue • Lack of appetite • Runny nose • Sore throat • Cough - Vomiting or nausea - Diarrhea

Control in birds: 1. Rapid destruction (culling or stamping out of all infected or exposed birds) proper disposal of carcasses and quarantining and rigorous disinfection of farms 2. Restriction of movement of live poultry In humans: 1. Influenza vaccination 2. Avoid contact with poultry animals or migratory birds Diagnostic: Nasopharyngeal (throat) swab Immunofluorescent antibody testing – to distinguish influenza A and B Treatment: Antiviral medications may reduce the severity and duration of symptoms in some cases: Oseltamivir (Tamiflu) or zanamivir

Isolation technique Vaccination Proper cooking of poultry

- Cover your nose and mouth when coughing and sneezing - Always wash hands with soap and water - Use alcohol- based hand sanitizers - Avoid close contact with sick people - Increase your body's resistance - Have at least 8 hours of sleep - Be physically active - Manage your stress - Drink plenty of fluids - Eat nutritious food

ROBERT C. REÑA, BSN REFERENCES:  THE ROYAL PENTAGON REVIEW SPECIALISTS, INC NOTE-TAKING GUIDE FOR COMMUNICABLE DISEASE NURSING by DANIEL JOSEPH E. BERDIDA, RM, RN  CHAPTER VII: COMMUNICABLE DISEASE PREVENTION and CONTROL, PUBLIC HEALTH NURSING IN THE PHILIPPINES, 10th EDITION  DEPARTMENT OF HEALTH OFFICIAL WEBSITE: www.doh.gov.ph  CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) OFFICIAL WEBSITE: www.cdc.gov