Tropical Medicine - Midwives Revision

Tetanus

Tetanus is an acute infectious disease of the central nervous system caused by clostridium tetani and is characterized by spasms of the skeletal muscles frequently attacking the muscles of the jaw.

Tetanus is commonly known as ‘Lock-jaw.’

Tetanus is a severe bacterial infection characterized by intermittent spasms (twitching) of voluntary muscles.

It is caused by the neurotoxin tetanospasmin produced by Clostridium tetani, an anaerobic bacterium commonly found in soil, dust, and animal feces. The incubation period ranges from a few days to several weeks (averaging 7-10 days), with shorter periods indicating a more severe infection.

Causative Agent and Transmission:

Tetanus is caused by the exotoxins of clostridium tetani.

The causative agent is Clostridium tetani, whose spores enter the body through various routes:

Deep penetrating wounds: Puncture wounds, lacerations, burns, and crush injuries provide anaerobic conditions ideal for spore germination.
Umbilical cord: In newborns (neonatal tetanus), infection often arises from an unsterile umbilical cord stump.
Other routes: Ear infections, wounds sustained during delivery, and septic abortions can also serve as entry points.
The organism can live for a long time in any condition, especially dirty environments. So it can be found in dust, soil, or grass.
The clostridia can be normal organisms in the alimentary canal of animals but when passed out and gain entry to the human body, they become harmful. The organism can be found in cows, horse, sheep, or goat.

Incidence of tetanus:

In babies born at home before arrival at the hospital.
In homes where domestic animals are kept.

Pathophysiology of Tetanus

The pathophysiology of tetanus involves the invasion of the body by bacilli or spores, typically through deep puncture wounds or cuts. These bacilli find a suitable environment to multiply in anaerobic conditions. It is crucial to note that all unclean wounds pose a significant risk. Once the clostridium tetani organisms enter the wound, they unleash two forms of exotoxins into the surrounding tissues: tetanospasmin and tetanolysin.

Tetanospasmin, a potent toxin, plays a critical role in producing the disease’s clinical manifestations. It primarily affects the central nervous system (CNS). The toxins specifically target the motor nerve cells of the spinal cord and the brain. As a result, spasms develop in the muscles that are supplied by the corresponding nerves.

Route of entry

The route of entry for the clostridium tetani organisms includes various pathways, all of which can lead to infection and subsequent tetanus:

Infected ulcerated wound.
Postoperative wounds.
Umbilical stumps (in newborns).
Gun-shot wounds.
Septic abortion.
Jiggers or foreign bodies.
Burns and scalds.

Clinical Features of Tetanus:

Symptoms typically begin with localized muscle stiffness, progressing to more generalized manifestations:

Trismus (Lockjaw): Difficulty opening the mouth due to masseter muscle spasm. Stiffness of the muscles, particularly noticeable in the jaw. Spasms affecting the muscles of the face, especially the cheek and jaw, leading to difficulty in opening the mouth, a condition referred to as trismus.
Risus sardonicus: A characteristic grimace with a sardonic smile. The angles of the mouth are pulled outwards, causing a forced smile known as risus sardonicus or the “Devil’s grin.”
Dysphagia: Difficulty swallowing. Swallowing becomes challenging as the muscles of the mouth and esophagus are affected by spasms.
Weight loss may occur due to difficulties in eating, leading to starvation.
Muscle spasms: Severe, painful spasms initially affecting the jaw and neck, then spreading to other muscle groups. Spasms can be triggered by stimuli such as sounds or light.
Opisthotonos: Severe arching of the back due to muscle spasms, while the patient remains conscious. The head is thrown back, and the back becomes arched due to the rigid muscles in the neck, a condition called opisthotonus.
Fever: Often present. Patients may experience an elevated temperature and rapid pulse.
Signs of inflammation may be evident, such as swelling of the umbilical cord (if present in newborns), a wet cord, offensive smell, or pus discharge from the wound site.
Respiratory distress: Spasms of respiratory muscles can cause respiratory failure, a life-threatening complication. Spasms affecting the respiratory muscles may lead to prolonged periods without oxygen (anoxia), which can be life-threatening and result in death.
Autonomic nervous system instability: This can lead to fluctuating blood pressure, sweating, and tachycardia.
Hyperreflexia: Exaggerated reflexes.
Absence of a visible wound: Does not exclude a diagnosis of tetanus; infection can sometimes occur without a readily apparent wound.
Spasms of the sphincters can result in retention of urine or stool, and in severe cases, sphincter rupture may occur.
Patients may have a wound or a history of a wound, which could be the point of entry for the tetanus-causing bacteria.

Alblett Classification of Tetanus

There are several grading systems; the scale proposed by Ablett5
is the most widely used . This categorizes patients
into four grades depending upon the intensity of spasms, and
respiratory and autonomic involvement.

Management of Tetanus

There’s no cure for tetanus. A tetanus infection requires emergency and long-term supportive care while the disease runs its course.

Aims of Management

To control spasms.
To eliminate the causative organism and its toxins.
To prevent complications, and ensure adequate nutrition for the patient.

Specific treatment measures include:

Penicillin: Administering penicillin is a crucial step in destroying the tetanus-causing organism.
Anti-tetanus serum: The administration of anti-tetanus serum helps neutralize the spreading toxins and halt their further detrimental effects.
Sedation and muscle relaxants: Medications like diazepam and chlorpromazine are given to provide sedation and muscle relaxation, effectively alleviating spasms and minimizing discomfort.
Wound management: If there is a wound or focus of infection where the tetanus bacteria may have entered, the dead tissue is excised, and the area is irrigated with hydrogen peroxide. Leaving the wound open without suturing promotes oxygen exposure, hindering the growth of tetanus bacilli, which thrive in anaerobic conditions.

Neutralizing the Toxin:

Tetanus Immunoglobulin (TIG): Human TIG is administered to neutralize circulating toxins. The dose varies depending on age and the severity of the contamination:

Adults and children: 150 IU/kg (administered at least in two different IM sites, separate from the tetanus toxoid injection site).
Neonates: 500 IU IM (in at least two different IM sites).

Tetanus Toxoid (TT) or DPT: The appropriate vaccine (TT or DPT) should be administered immediately to provide active immunity. Refer to the vaccination guidelines for specific age-appropriate regimens.

Eliminating the Source of Toxin:

Wound management: Thorough cleaning and debridement of wounds to remove necrotic tissue and eliminate the bacterial source. For umbilical wounds in neonatal tetanus, meticulous cleaning and debridement of the umbilical stump are essential.

Antibiotic Treatment:

First-line: Metronidazole (500 mg every 8 hours IV or orally for 7 days; children: 7.5 mg/kg every 8 hours).
Second-line: Benzylpenicillin (2.5 MU every 6 hours for 10 days; children: 50,000-100,000 IU/kg per dose; Neonates: 100,000 IU/kg every 12 hours for 10-14 days)

Control of Muscle Spasms:

First-line: Diazepam (10 mg IV or rectal every 1-4 hours; children: 0.2 mg/kg IV or 0.5 mg/kg rectal every 1-4 hours, max 10mg). For Neonates: 0.2 mg/kg IV or 0.5 mg/kg rectal every 1 to 4 hours.
Other agents: Magnesium sulfate (alone or with diazepam), chlorpromazine (alone or alternating with diazepam). Monitor for side effects (e.g., respiratory depression with diazepam, loss of knee-jerk reflex with magnesium sulfate). Chlorpromazine dosage for neonates: 1 mg/kg orally 8 hourly via NGT.

Pain Control:

Morphine: (2.5-10 mg IV every 4-6 hours; monitor for respiratory depression; children: 0.1 mg/kg per dose).
Paracetamol: (1 g every 8 hours; children: 10 mg/kg every 6 hours).

Prevention:

Routine childhood immunization: All children should receive the recommended tetanus toxoid-containing vaccines (DTP, Tdap, or Td) as per national immunization schedules.
Proper wound care: Prompt and appropriate treatment of wounds, including cleaning and debridement, significantly reduces the risk.
Prophylactic TIG: For individuals with contaminated wounds and incomplete or unknown immunization status:

Children < 5 years: 75 IU
Children 5-10 years: 125 IU
Children > 10 years and adults: 250 IU

Wound care: Proper care of wounds, including thorough cleaning and debridement, helps prevent infection.

Control of spasms involves the following measures:

Absolute rest and isolation: The patient should be kept in a quiet room with dim lighting to minimize triggers for spasms.
Prevention of external stimuli: Measures such as fitting the door with suitable closing materials or springs prevent slamming noises that could stimulate the patient.
Warming hands before touching: Nurses should warm their hands before touching the patient to avoid any stimulation that might trigger spasms.
Medication administration: Sedatives and muscle relaxants, such as chlorpromazine (Largactil), and Diazepam, are given regularly through a nasogastric tube to maintain a controlled state and alleviate spasms.

o Example of 6 hourly regimen

Drug

6-9

9-12

12-3

3-6

6-9

9-12

12-3

3-6

6-9

Largactil

⫼⫼⫼⫼

Diazepam

⫼⫼⫼⫼

General Management:

Close observation and airway management: Monitor the patient closely, ensuring a clear airway and using a mucous extractor if necessary.
Vital signs monitoring: Regularly check temperature, pulse, and respirations, noting the severity of the condition. Record the strength, frequency, duration, and body part involved in spasms using a spasm chart.
Nutrition: Maintain adequate nutrition through nasogastric tube feeding to avoid stimulating spasms with injections. Prevent aspiration of fluids into the airway.
Catheterization: Catheterize the patient to maintain proper bladder function.
Fluid balance chart: Monitor and maintain fluid balance, initially using intravenous fluids if necessary and later transitioning to nasogastric tube feeding.
Hygiene: Ensure daily cleaning of the cord with normal saline and perform oral care carefully. Turn the patient every two hours to prevent pressure sores.
Vaccination: Prevent future tetanus cases by ensuring all individuals receive a full course of DPT (diphtheria, pertussis, and tetanus) vaccination.
Use sterile equipment: Prevent cross-infection by using sterile equipment during medical procedures.
Bowel and bladder care: Monitor and assist the patient in passing stool and urine.
Medication: Administer prescribed drugs as instructed.
Physiotherapy: Implement physiotherapy sessions for deep breathing exercises and active limb movements.

Prevention:

Public health education: Raise awareness about the dangers of using unsterilized equipment during childbirth and applying native medicine or other substances to the umbilical cord.
Immunization: Ensure that all women of childbearing age are vaccinated against tetanus.
Safe childbirth practices: Promote safe and clean practices during childbirth to prevent infections.
Discourage harmful practices: Discourage practices like applying cow dung to a child’s umbilical cord.
Wound care education: Educate people on cleaning wounds thoroughly with water and soap to prevent infections. Encourage covering wounds with sterile dressings and seeking early medical attention for cut wounds.
Protective gear: Encourage the use of gum boots when digging to prevent soil-related infections.

Complications of Tetanus

Fracture of bones or the spine: The intense and frequent muscle spasms can cause fractures in bones or the spine, especially if the spasms are severe and uncontrolled.
Pneumonia: Heavy sedation, a common treatment for managing tetanus spasms, may lead to shallow breathing or difficulty in clearing the airway, increasing the risk of pneumonia, a potentially severe respiratory infection.
Brain damage: The potent toxins produced by the tetanus-causing bacteria can affect the central nervous system, leading to brain damage in severe cases.
Growth retardation: In children affected by tetanus, the disease can interfere with proper nutrition and growth, potentially causing growth retardation.
Exhaustion: The continuous and strenuous muscle spasms can lead to extreme exhaustion, further weakening the patient’s overall condition.
Respiratory failure: In severe cases, the spasms can affect the respiratory muscles, resulting in respiratory failure, where the patient is unable to breathe adequately on their own.
Retention of urine: Spasms in the pelvic region can cause the sphincters to contract, leading to difficulty in passing urine and possible urine retention.
Death due to airway obstruction: In the most severe cases, the intense spasms, particularly those affecting the muscles of the jaw and neck, can obstruct the airway, leading to suffocation and potential death.

Test Questions

Which bacterium causes tetanus?
a) Streptococcus pyogenes
b) Staphylococcus aureus
c) Clostridium tetani
d) Escherichia coli
Answer: c) Clostridium tetani

Explanation: Clostridium tetani is the bacterium responsible for causing tetanus.

What is the common term used to describe tetanus due to spasms in the jaw muscles?
a) Trismus
b) Opisthotonus
c) Risus sardonicus
d) Tetanospasmin
Answer: a) Trismus

Explanation: Trismus is the medical term for difficulty in opening the mouth due to jaw muscle spasms, which is commonly known as “Lock-jaw.”

What is the primary goal of managing tetanus?
a) Preventing complications
b) Destroying the toxin
c) Controlling fever
d) Alleviating pain
Answer: a) Preventing complications

Explanation: The main aim of managing tetanus is to prevent complications associated with the disease and ensure the best possible outcome for the patient.

What is the specific treatment given to destroy the tetanus-causing organism?
a) Penicillin
b) Paracetamol
c) Aspirin
d) Ibuprofen
Answer: a) Penicillin

Explanation: Penicillin is administered to destroy the Clostridium tetani bacterium responsible for causing tetanus.

Which complication of tetanus can lead to respiratory failure?
a) Pneumonia
b) Fracture of bones
c) Brain damage
d) Respiratory muscle spasms
Answer: d) Respiratory muscle spasms

Explanation: Tetanus-induced spasms affecting the respiratory muscles can lead to respiratory failure, where the patient is unable to breathe adequately on their own.

Why is the use of a mucous extractor important in tetanus management?
a) To prevent dehydration
b) To clear the airway
c) To alleviate muscle spasms
d) To prevent fever
Answer: b) To clear the airway

Explanation: A mucous extractor is used to clear the airway and prevent obstruction caused by excessive secretions, which is crucial in tetanus management.

What is the recommended method for feeding tetanus patients to avoid spasms triggered by injections?
a) Intravenous feeding
b) Nasogastric tube feeding
c) Oral feeding
d) Intramuscular injections
Answer: b) Nasogastric tube feeding

Explanation: Nasogastric tube feeding is used to provide nutrition and administer drugs to tetanus patients while avoiding the stimulation of spasms caused by intramuscular injections.

Which immunization should be given to prevent future tetanus cases?
a) Hepatitis B
b) Measles, Mumps, and Rubella (MMR)
c) Diphtheria, Pertussis, and Tetanus (DPT)
d) Polio
Answer: c) Diphtheria, Pertussis, and Tetanus (DPT)

Explanation: The DPT vaccine provides immunity against diphtheria, pertussis (whooping cough), and tetanus, preventing future tetanus cases.

What measure can be taken to prevent tetanus in newborns with umbilical stumps?
a) Cleaning the stump with cow dung
b) Applying native medicine on the stump
c) Keeping the stump dry and clean
d) Ignoring the stump until it falls off naturally
Answer: c) Keeping the stump dry and clean

Explanation: Maintaining cleanliness and dryness of the umbilical stump can prevent infection and the risk of tetanus in newborns.

What is the purpose of physiotherapy in tetanus management?
a) To provide pain relief
b) To promote muscle strength
c) To control spasms
d) To increase body temperature
Answer: b) To promote muscle strength

Explanation: Physiotherapy aims to promote muscle strength and mobility, which can be helpful in the recovery process of tetanus patients.

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Leprosy

Leprosy, also known as Hansen’s disease, is a chronic infection caused by the bacteria Mycobacterium leprae and Mycobacterium lepromatosis.

It primarily affects the skin and peripheral nerves.

Cause of Leprosy

Leprosy is caused by Mycobacterium leprae and Mycobacterium lepromatosis. M. lepromatosis is a relatively newly identified mycobacterium isolated from a fatal case of diffuse lepromatous leprosy in 2008.

Transmission of Leprosy

Nasal route via secretions
Transplacental and breast feeding
Genetic predisposition

Types of Leprosy:

Lepromatous leprosy (90%): This is the most common type of leprosy, accounting for about 90% of cases. It is characterized by widespread skin lesions and a weak cellular immune response. The bacteria multiply profusely in the body, leading to severe skin and nerve damage.
Tuberculoid leprosy: In this type, the immune response is stronger, and the skin lesions are few and well-defined. The affected areas may have a loss of sensation, but nerve damage is less severe compared to lepromatous leprosy.
Borderline leprosy: Borderline leprosy lies in between lepromatous and tuberculoid leprosy in terms of immune response and clinical features. It displays mixed characteristics, with moderate skin lesions and nerve involvement.
Undeterminate (Dismorphoid or Undetermined) leprosy: This type is diagnosed when the symptoms and immune response are not well-defined, making it difficult to classify precisely. It often occurs early in the disease’s progression and may eventually develop into one of the other types.

Differences between Tuberculoid, Lepromatous and Borderline leprosy

Cutaneous lesion	Tuberculoid	Lepromatous	Borderline
Characteristic number of lesions	Few	Many	Many
Size of lesion	Large	Small	Both – large & small
Symmetry of lesions	Asymmetrical	Symmetrical	Symmetrical
Surface of lesions	Rough and scaly	Smooth	Rough & scaly
Edges	Sharp	Vague	Sharp

Incubation Period:

The incubation period of leprosy refers to the time between when a person is exposed to the bacteria Mycobacterium leprae and the onset of symptoms. In leprosy, this period usually lasts from 2 to 5 years. However, in certain cases, especially in lepromatous leprosy, the incubation period may extend to a longer duration, lasting 8 to 12 years before signs of the disease become apparent.

Signs and Symptoms:

Leprosy presents with a variety of signs and symptoms, which may vary depending on the type and stage of the disease. Some common manifestations include:

Anaesthetic skin lesions: These are patches of skin that lose their ability to feel sensation. Individuals may not be able to detect pain, heat, or touch in these areas, making them prone to injuries.
Thickened peripheral nerves: Leprosy can affect the peripheral nerves, leading to their thickening and enlargement, often seen as lumps under the skin.
Nasal stuffiness: In some cases, leprosy can cause inflammation and swelling in the nasal passages, leading to nasal stuffiness and congestion.
Saddled nose (Saddle nose): This refers to the collapse of the nasal bridge due to the destruction of the nasal septum, which can occur in advanced cases of leprosy.
Loss of eyebrows and lashes: Leprosy can cause the loss of eyebrows and eyelashes, leading to changes in facial appearance.
Erythema nodosum: This is a condition characterized by painful, red nodules that can occur on the skin or under the skin’s surface.
Inflammatory eye changes: Leprosy may affect the eyes, leading to various eye problems, including inflammation and potential vision impairment.

Investigations

To diagnose leprosy and confirm the presence of Mycobacterium leprae, healthcare professionals may conduct several investigations, such as:

Histamine test: This test helps assess the level of nerve damage by evaluating the body’s response to histamine injection.
Lepromine test: Lepromine is a substance derived from the leprosy bacteria. The test measures the immune response to lepromine to determine the type of leprosy and the individual’s immune status.
Polymerase Chain Reaction (PCR): PCR is a molecular technique used to detect the genetic material of the bacteria in skin samples, aiding in early and accurate diagnosis.
Skin snip for Mycobacterium leprae (modified ZN): A small sample of skin is taken and stained using the modified Ziehl-Neelsen method to visualize the presence of Mycobacterium leprae under a microscope.

Treatment for Leprosy:

Tuberculoid leprosy:
- Dapsone + Rifampicin
Lepromatous leprosy:
- Dapsone + Rifampicin + Clofazimine
Borderline leprosy:
- Dapsone

Non-leprosy drugs used in the management of leprosy:

Steroids
Vitamin B complex

Drugs for leprosy are commonly administered in fixed drug combinations known as MDT (Multi-Drug Therapy). MDT has been a highly effective approach in treating leprosy and preventing the development of drug resistance.

Complications of leprosy include:

Madorosis (loss of eyebrows and eyelashes)
Nasal bridge collapse
Ocular complications: corneal ulcer, blindness
Leonine faces (thickened, lion-like appearance of facial skin)
Loss of sensation to heat, pain, and light touch
Multiple ulcerations due to nerve damage and loss of sensation
Nerve enlargement
Orchitis (inflammation of the testicles)
Disuse of some parts of the body
Contractures and shortening of phalanges, especially the 4th and 5th fingers and toes
Elongated soft ear lobes
Sterility in men secondary to orchitis
Hammer toes (abnormal bending of the toes)
Reactional states secondary to successful drug therapy (erythema nodosum leprosum).

Test Questions

Question: Leprosy primarily affects which body parts?
a) Liver and kidneys
b) Skin and peripheral nerves
c) Lungs and heart
d) Brain and spinal cord
Answer: b) Skin and peripheral nerves
Explanation: Leprosy is a chronic infection that primarily affects the skin and peripheral nerves.

Question: What is the incubation period for lepromatous leprosy?
a) 1-2 years
b) 3-5 years
c) 6-8 years
d) 8-12 years
Answer: d) 8-12 years
Explanation: Lepromatous leprosy has a longer incubation period of 8-12 years, compared to other types of leprosy.

Question: Which type of leprosy has well-defined, few skin lesions and less severe nerve damage?
a) Tuberculoid leprosy
b) Lepromatous leprosy
c) Borderline leprosy
d) Indeterminate leprosy
Answer: a) Tuberculoid leprosy
Explanation: Tuberculoid leprosy is characterized by well-defined, few skin lesions and less severe nerve damage.

Question: Which drug combination is used to treat lepromatous leprosy?
a) Dapsone
b) Dapsone + Rifampicin
c) Dapsone + Rifampicin + Clofazimine
d) Rifampicin
Answer: c) Dapsone + Rifampicin + Clofazimine
Explanation: Lepromatous leprosy is treated with a combination of Dapsone, Rifampicin, and Clofazimine.

Question: What are the complications of leprosy that may lead to blindness?
a) Loss of eyebrows and lashes
b) Nasal bridge collapse
c) Corneal ulcer
d) Erythema nodosum leprosum
Answer: c) Corneal ulcer
Explanation: Leprosy can cause corneal ulcers, which may lead to blindness if left untreated.

Question: Which investigation helps diagnose leprosy by detecting Mycobacterium leprae in skin samples?
a) Lepromine test
b) Histamine test
c) PCR
d) Skin snip for Mycobacterium leprae (modified ZN)
Answer: d) Skin snip for Mycobacterium leprae (modified ZN)
Explanation: Skin snip test with modified Ziehl-Neelsen staining is used to visualize Mycobacterium leprae under a microscope.

Question: What is the most common type of leprosy?
a) Tuberculoid leprosy
b) Lepromatous leprosy
c) Borderline leprosy
d) Indeterminate leprosy
Answer: b) Lepromatous leprosy
Explanation: Lepromatous leprosy is the most common type, accounting for about 90% of leprosy cases.

Question: Which type of leprosy has a weak cellular immune response and widespread skin lesions?
a) Tuberculoid leprosy
b) Lepromatous leprosy
c) Borderline leprosy
d) Indeterminate leprosy
Answer: b) Lepromatous leprosy
Explanation: Lepromatous leprosy is characterized by a weak cellular immune response and widespread skin lesions.

Question: What is the term used to describe the thickened, lion-like appearance of facial skin in leprosy?
a) Madorosis
b) Leonine faces
c) Erythema nodosum
d) Nasal bridge collapse
Answer: b) Leonine faces
Explanation: Leonine faces refer to the thickened, lion-like appearance of facial skin seen in some cases of leprosy.

Question: Which non-leprosy drug is commonly used in the management of leprosy?
a) Antibiotics
b) Steroids
c) Antifungals
d) Antivirals
Answer: b) Steroids
Explanation: Steroids are used in the management of leprosy to control inflammation and reduce immune reactions in some cases.

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Tuberculosis

Tuberculosis, commonly known as TB (short for tubercle bacillus), is a widespread and often deadly infectious disease caused by various strains of mycobacteria.

While primarily affecting the lungs, it can also impact other parts of the body. Around one-third of the world’s population (1 in 3 or 3 out of 10 people) is affected by this condition. Individuals with HIV/AIDS have a higher risk of contracting tuberculosis.

Aetiology:

The disease is caused by mycobacterium tuberculosis, which is a small, aerobic, non-motile bacillus.

Mode of Spread

TB spreads through the air when individuals with an active infection cough, sneeze, or transmit respiratory fluids. Additionally, it can spread through the blood (haematogenous spread).

Types of Tuberculosis

Pulmonary tuberculosis.
Extra-pulmonary tuberculosis.
Primary and Secondary tuberculosis.

Clinical Features:

Pulmonary TB:

Fever and chills
Night sweats
Loss of appetite
Weight loss
Easy fatigability
Persistent cough lasting more than 3 weeks, with or without haemoptysis (coughing up blood)
Significant finger clubbing (abnormal swelling of the fingertips)
Chest pain
Productive cough or non-productive cough in smear-negative TB
Lymphadenopathy (swollen lymph nodes)

Extrapulmonary TB:

In approximately 15-20% of active TB cases, the infection spreads beyond the lungs, resulting in various forms of extrapulmonary tuberculosis. This type is more common in individuals with weakened immune systems and young children. In people with HIV, extrapulmonary TB occurs in more than 50% of cases.

Notable sites of extrapulmonary infection include:

The pleura, leading to tuberculous pleurisy.
The central nervous system, causing tuberculous meningitis.
The lymphatic system, resulting in TB lymph nodes.
The genitourinary system, causing urogenital tuberculosis.
The bones and joints, leading to Pott’s disease of the spine. When it affects the bones, it is known as “osseous tuberculosis,” a form of osteomyelitis.
Sometimes, a tubercular abscess may burst through the skin, resulting in a tuberculous ulcer. Ulcers originating from infected lymph nodes nearby are typically painless.
A potentially severe and widespread form of TB is “disseminated” TB, commonly known as miliary tuberculosis. Miliary TB accounts for about 10% of extrapulmonary cases.

Risk factors

Several factors increase the susceptibility of individuals to TB infections:

HIV infection is a significant global risk factor, contributing to 13% of all TB cases.
Tuberculosis is closely associated with overcrowding and malnutrition, making it a prevalent disease in impoverished communities.
Inhabitants and employees of places where vulnerable individuals gather, such as prisons and homeless shelters, face higher risks.
Medically underserved and resource-poor communities, as well as high-risk ethnic minorities, are more susceptible.
Children in close contact with high-risk patients are at increased risk.
Health care providers serving TB patients are also at higher risk.
Chronic lung disease is another significant risk factor.
Smokers have nearly double the risk of TB compared to nonsmokers.
Other conditions like alcoholism and diabetes mellitus can also elevate the risk of developing tuberculosis.

Epidemiology:

Approximately one-third of the world’s population is infected with tuberculosis.
TB causes 25% of preventable adult deaths, and three-fourths of these affected individuals are in their productive age.
South Eastern Asia has the highest number of TB cases.
Africa has the world’s highest incidence rate, with an annual incidence rate of 345 cases per 100,000 people.
The infection rate is higher in men than in women.

Primary Tuberculosis:

It occurs in individuals who have never been exposed to tubercle bacilli before.
Tubercle bacilli are inhaled and reach the lungs, where they multiply and can spread to the hilar lymph nodes through the lymphatic system and blood.
Approximately six weeks after the primary infection, the body’s immune response kicks in, preventing further multiplication of the tubercle bacilli.
Some bacilli may die, and the remaining ones are walled off by immune cells called epithelioid cells, forming a ghon focus. This ghon focus can persist for years in primary tuberculosis.
The ghon focus and hilar lymphadenopathy together form a primary complex in primary tuberculosis.
Only about 10% of those with primary infection progress to develop tuberculosis disease.

Secondary Tuberculosis:

This type of tuberculosis can result from either the reactivation of tubercle bacilli acquired during primary infection or reinfection by tubercle bacilli in a person previously exposed to the organisms.

Pathogenesis:

TB infection starts when mycobacteria reach the pulmonary alveoli and invade and replicate there.
In addition to the lungs, tuberculosis can spread through the bloodstream, leading to infection in distant sites like peripheral lymph nodes, kidneys, brain, and bones.
The infection triggers an inflammatory response, resulting in the formation of granulomas. Granulomas are collections of activated macrophages, T lymphocytes, B lymphocytes, and fibroblasts.
The tubercle bacilli are surrounded by lymphocytes, forming a peripheral rim and creating a Ghon focus. (see image below)
Inside the granulomas, the bacteria can become dormant, causing latent infection. Caseation, a type of abnormal cell death, occurs in the center of the tubercles.
In severe cases, where TB bacteria enter the bloodstream from damaged tissue, multiple foci of infection can develop throughout the body, appearing as tiny white tubercles in the tissues. This condition is known as miliary tuberculosis and is more common in young children and individuals with HIV.
Tissue destruction and necrosis are balanced by healing and fibrosis. Scarring and cavities filled with caseous necrotic material replace affected tissue.

Diagnosis (Investigations):

When tuberculosis is suspected, the following investigations can aid in confirming the diagnosis:

Signs of lung disease or constitutional symptoms lasting longer than two weeks.
Chest X-ray: Imaging the chest can reveal characteristic abnormalities, such as infiltrates, cavities, or nodules, which can indicate tuberculosis.
Multiple sputum cultures for acid-fast bacilli (AFB): Sputum samples are collected at different times, typically spot samples and early morning samples, to increase the chances of detecting the tuberculosis bacteria.
Tuberculin skin tests: Also known as the Mantoux or Heaf test, it is commonly used to assess TB infection in children and identify individuals at risk of developing tuberculosis.
Haematological tests:
- Full blood cell count (FBC): This test helps evaluate any abnormalities in blood cell counts that may be indicative of an infection or inflammation.
- Erythrocyte Sedimentation Rate (ESR): An elevated ESR can raise suspicion of tuberculosis, as it indicates inflammation in the body.
Tissue biopsy: In cases where tuberculosis affects extrapulmonary sites or when other tests are inconclusive, a biopsy of the affected tissue may be performed to examine the presence of tubercle bacilli.

Relationship between HIV and TB:

Effects of HIV on TB:

Development of active TB: Individuals infected with HIV have a higher risk of developing active tuberculosis once exposed to the TB bacteria.
High risk of re-infection: HIV-positive individuals are more susceptible to being infected with a second strain of TB after already having the infection.
Increased incidence of TB: The overall incidence of tuberculosis increases due to the higher prevalence of HIV, which weakens the immune system and makes individuals more susceptible to TB.
Changes in TB presentation: TB in HIV-positive individuals may present with clinical and bacteriological changes, such as a non-productive cough, absence of hemoptysis (coughing up blood), and a miliary pattern on imaging instead of cavitations.
Quicker development of TB complications: HIV accelerates the progression of TB and its associated complications.

Effects of TB on HIV:

Increased HIV replication: TB infection can enhance the replication of HIV, leading to a higher viral load and faster progression to AIDS.
Common opportunistic infection: TB is one of the most common opportunistic infections in individuals living with HIV and is a leading cause of death in this population.
Interference with ARV treatment: Some anti-TB medications, such as Rifampicin, can interfere with certain antiretroviral drugs (ARVs), like Nevirapine and protease inhibitors, necessitating adjustments in treatment.

Consequences of dual infection with HIV and TB:

Increased morbidity and mortality.
Higher recurrence rate of TB after completing treatment.
Drug resistance leading to multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB).
Higher rates of treatment non-adherence due to overlapping medication regimens.
Increased risk of drug toxicity from the combined treatment.

Management of HIV and TB co-infection:

Prioritize TB treatment before starting ARVs.
Start ARVs if CD4 count is below 350 cells/mm³, either after finishing TB treatment or during the intensive phase, depending on the clinical situation.
Consider drug interactions between TB and HIV regimens when selecting medications.
Use directly observed therapy (DOTs) for TB treatment and closely monitor patients for toxicity and adherence.
Administer prophylaxis for opportunistic infections as indicated.

Complications of TB:

Pleural effusion: Accumulation of fluid in the pleural space of the lungs.
Pericardial effusion: Accumulation of fluid around the heart.
Empyema: Pus-filled cavity in the pleural space.
Pneumothorax: Presence of air or gas in the pleural cavity, causing lung collapse.
Lung fibrosis: Scarring of lung tissue, leading to impaired lung function.
Lung collapse: Collapse of a lung or part of a lung due to blockage or compression.
Extra-pulmonary TB: TB affecting organs other than the lungs, such as TB meningitis.

Treatment of TB:

Aims of TB Treatment:

To cure the patient of tuberculosis.
To prevent complications and death from TB.
To reduce the transmission of TB to others.

Case Definitions:

New Case: A person who has never received TB treatment or has taken TB treatment for four weeks or less.
Relapse: A patient who was previously diagnosed with TB, completed the course of anti-TB drugs, was declared cured, but has now become smear positive again.
Failure: A person who continues to be smear positive at five months, despite adequately taking anti-TB drugs, or who was smear negative and becomes smear positive at two months.
Defaulter: A patient who starts taking anti-TB drugs for more than four weeks but interrupts treatment (stops taking the drugs) for four weeks or more.

Drugs Used in TB Treatment:

Rifampicin (R)
Isoniazid (H or INH)
Ethambutol (E)
Pyrazinamide (Z)
Streptomycin (S)

Standard TB Treatment Regimen:

The World Health Organization (WHO) recommends a standard six-month treatment regimen for drug-sensitive TB cases, which typically includes the following four drugs for the first two months:

Rifampicin (R)
Isoniazid (H)
Pyrazinamide (Z)
Ethambutol (E)

This initial phase is followed by a continuation phase for the next four months, during which the drugs used may vary depending on the patient’s response to treatment and drug sensitivity testing.

It’s important to note that TB treatment should be administered under direct observation (DOTs) whenever possible to ensure proper adherence and to prevent the development of drug-resistant TB strains. Check DOT below in details.

Treatment regimen

Short course TB treatment regimen

Patient category (type of TB)	Initial phase	Continuation phase
1. New smear positive 2. New smear negative 3. Severe extra-pulmonary	2EHRZ	6EH
4. Previously treated smear POSITIVE: – Relapse – Failure to respond – Return after interruption	2SEHRZ/1EHRZ	5EHR
5. Any form of TB in children 6. Adult non-severe extra pulmonary	2HRZ	4HR

Non-anti-TB Drugs Used in TB:

Pyridoxine (Vitamin B₆): Administered to prevent or treat peripheral neuropathy, a side effect of Isoniazid (H) used in TB treatment. Pyridoxine supplementation helps prevent nerve damage caused by Isoniazid.
Steroids: Used as adjunct therapy in specific forms of TB to reduce inflammation and improve outcomes. Steroids are commonly used in the treatment of:
- TB Meningitis
- TB Pericarditis
- TB of Adrenals

DOTS (Directly Observed Therapy Short course):

How it works:

DOTS is a community-based TB care approach adopted by countries to improve TB treatment outcomes.
Trained workers or treatment supporters ensure that patients take their daily treatment doses and record the administration on the TB card.
DOTS is the standard of care for all TB cases and suspects.
It helps decrease relapse, defaulter rates, and the development of acquired drug resistance.
When combined with other measures, DOTS promotes treatment adherence.
After diagnosing TB and initiating treatment, the diagnostic center records the information in the health unit’s TB register.
The sub-county health worker transfers this information to the sub-county health worker register and identifies a treatment supporter in the patient’s village.
The treatment supporter is trained to observe the patient taking their treatment, record it on the TB card, keep the drugs, and remind the patient of follow-up assessments at the health unit at 2 months, 5 months, and 8 months.
The sub-county health worker collects medication from the health unit and delivers it to the treatment supporter.

Prevention of TB:

Early detection and proper management of TB cases.
Early case findings to identify and treat TB cases promptly.
Health education to raise awareness about TB transmission and prevention.
Training of all health workers to recognize early signs of TB.
Vaccination of children with the Bacille Calmette-Guérin (BCG) vaccine to protect against severe forms of TB in childhood.
Prophylaxis with Isoniazid for individuals at high risk of developing TB, such as those with latent TB infection or individuals with HIV.
Prevention and management of medical conditions like HIV, which increase the risk of TB.
Implementation of the DOTS program to improve treatment adherence and outcomes.

Test Questions

Question: Which bacterium is responsible for causing tuberculosis?

a) Streptococcus pneumoniae
b) Mycobacterium tuberculosis
c) Escherichia coli
d) Staphylococcus aureus

Answer: b) Mycobacterium tuberculosis
Explanation: Mycobacterium tuberculosis is the specific bacterium that causes tuberculosis.

Question: What is the most common site of TB infection in the human body?
a) Liver
b) Lungs
c) Heart
d) Kidneys

Answer: b) Lungs
Explanation: Pulmonary tuberculosis is the most common form of TB, affecting the lungs.

Question: In HIV-positive individuals, the risk of developing active tuberculosis:
a) Decreases
b) Stays the same
c) Increases
d) Remains unaffected

Answer: c) Increases
Explanation: HIV weakens the immune system, making individuals more susceptible to developing active tuberculosis once infected with Mycobacterium tuberculosis.

Question: Which of the following is NOT a clinical feature of pulmonary tuberculosis?
a) Fever and chills
b) Night sweats
c) Loss of appetite
d) Severe abdominal pain

Answer: d) Severe abdominal pain
Explanation: Severe abdominal pain is not a typical clinical feature of pulmonary tuberculosis.

Question: What is the standard duration of treatment for drug-sensitive tuberculosis?
a) 3 months
b) 6 months
c) 9 months
d) 12 months

Answer: b) 6 months
Explanation: The standard treatment regimen for drug-sensitive TB lasts for 6 months.

Question: In which form of TB, patients may present with a non-productive cough and a miliary pattern on imaging?
a) Drug-resistant TB
b) Extrapulmonary TB
c) Latent TB
d) Multidrug-resistant TB

Answer: b) Extrapulmonary TB
Explanation: Extrapulmonary TB can present with atypical symptoms like a non-productive cough and a miliary pattern on imaging.

Question: What is the main purpose of the DOTS program in TB management?
a) To prevent TB transmission
b) To promote TB vaccination
c) To monitor drug resistance
d) To improve treatment adherence

Answer: d) To improve treatment adherence
Explanation: The main aim of the DOTS program is to ensure that patients adhere to their TB treatment, which leads to better outcomes and reduced relapse rates.

Question: Which non-anti-TB drug is used to prevent or treat peripheral neuropathy, a side effect of Isoniazid?
a) Vitamin C
b) Vitamin D
c) Pyridoxine (Vitamin B₆)
d) Folic acid

Answer: c) Pyridoxine (Vitamin B₆)
Explanation: Pyridoxine is used to prevent or treat peripheral neuropathy caused by Isoniazid.

Question: TB Meningitis is best managed with the addition of which adjunct therapy?
a) Antibiotics
b) Antifungals
c) Antivirals
d) Steroids

Answer: d) Steroids
Explanation: TB Meningitis is often treated with the addition of steroids to reduce inflammation and improve outcomes.

Question: What is the primary aim of TB prevention?
a) Eradicate Mycobacterium tuberculosis from the environment
b) Reduce the incidence of drug-resistant TB
c) Prevent the transmission of TB from person to person
d) Increase vaccination coverage in high-risk populations

Answer: c) Prevent the transmission of TB from person to person
Explanation: The primary aim of TB prevention is to break the chain of transmission by preventing the spread of Mycobacterium tuberculosis from infected individuals to others.

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MEASLES/Rubeola

Measles, also known as Morbilli, is a highly contagious acute infection of the respiratory system caused by the morbillivirus.

It is characterized by a widespread skin rash, fever, and inflammation of the mucous membranes.

Measles, also known as rubeola, is a highly contagious, acute viral infection characterized by a generalized skin rash accompanied by pathognomonic Koplik’s spots.

The transmission of measles occurs through respiration, mainly by coming into contact with fluids from the nose and mouth of an infected person. Due to its high contagion, it can easily spread among individuals.

Aetiology (Cause):

Measles is caused by the measles virus, a single-stranded RNA virus belonging to the genus Morbillivirus within the family Paramyxoviridae. The virus is a multi-shaped, spherical structure with a diameter of 100-250 nm. It consists of six proteins, an inner capsid containing a helical strand of RNA, and an outer envelope.

Transmission:

The primary route of transmission is airborne, through inhalation of respiratory droplets expelled by an infected person during coughing, sneezing, or talking. Other transmission routes include:

Ingestion (fecal-oral): Transmission through contaminated food or water containing infected stool.
Direct contact: Contact with infected stool or contaminated objects.

Incubation Period:

The incubation period for measles is usually 10-14 days.

Patients are contagious for 1 to 2 days before the onset of symptoms and remain infectious for up to 4 days after the appearance of the rash. Infectivity peaks during the prodromal phase.

Risk Factors

Several risk factors increase the likelihood of contracting measles, including:

Immunodeficiency in children.
Traveling to regions where measles is common or having contact with individuals who have visited these areas.
Malnutrition, which can weaken the immune system.
Pregnancy, as it may increase susceptibility to the virus.
Vitamin A deficiency, which can compromise the body’s ability to fight infections.

Pathogenesis and Pathology:

After entering the respiratory system, the measles virus infects the respiratory epithelium and spreads via the bloodstream to various organs, including the skin, respiratory tract, and other systems. The virus infects white blood cells, contributing to the establishment of infection.

Generalized Damage: The respiratory system is particularly susceptible to damage, leading to loss of cilia and increasing susceptibility to secondary bacterial infections like pneumonia and otitis media.
Immune Response: The body mounts an immune response, but this can cause inflammation and damage to tissues.

Signs and Symptoms of Measles (Stages):

Measles, an acute and highly communicable infection caused by the morbillivirus, presents a clinical picture that can be divided into three distinct stages: prodromal, eruptive, and convalescent. Suspecting measles becomes crucial when patients exhibit the classic triad of the three “Cs”: cough, conjunctivitis, and coryza.

Stage 1: Prodromal Phase (3 days):

The incubation period lasts approximately 10-14 days.
Patients may not show any signs or symptoms during this stage.
Abrupt onset of mild to moderate symptoms, characterized by:
- Fever
- Headache
- General malaise
- Loss of appetite (anorexia)
- Enlarged neck lymph nodes
- Abdominal pain
- Diarrhea
- Vomiting

Stage 2: Eruptive Stage(Exanthem (Rash)

Abrupt onset with severe symptoms, including:
- Very high fever
- Cough
- Photophobia (sensitivity to light)
- Red eyes and conjunctivitis
- Hoarseness of the voice
- Distinctive Koplik spots on the mucous membrane of the mouth, next to the molar teeth. These spots may disappear once the rash appears.
Temperature rises on the first day (37.8-39.4 degrees Celsius), may slightly fall on the third day, then rise again on the fourth day with the onset of the rash.
The rash appears around the fourth day and starts on the forehead, behind the ears, neck, and then spreads over the face and entire body. The rash is a red maculo-papular eruption, giving the face a bloated, swollen appearance.

Stage 3: Convalescent Stage

Improvement and disappearance of signs and symptoms begin.
Key features include:
- Desquamation of the skin (shedding of the rash)
- A decline in body temperature
- Resolution of hoarseness of the voice
- Weight gain as the patient’s condition improves.

Predisposing Factors:

Unprotected communities with low immunization coverage: Lack of vaccination is a primary risk factor.
Malnourished children: Nutritional deficiencies weaken the immune system.
Overcrowding and poor ventilation: Close contact and enclosed spaces facilitate transmission.
Children with previous severe infections: Prior illnesses, like tuberculosis, can compromise immune function.

Nursing Care/Management for a Patient within 72 Hours of Measles:

Aims of Care/Management:

To reduce body temperature.
To correct dehydration.
To prevent further complications.

Admission:

Admit the child to a well-ventilated room in an isolation unit in the children’s ward.
Record the patient’s particulars, including name, age, next of kin, and full address on the admission forms.
Reassure the mother/caregiver about the child’s condition.

Observations:

Monitor vital signs (Temperature, pulse, respiration, blood pressure, and weight) and record them in an observation chart for baseline monitoring.
Conduct a comprehensive head-to-toe assessment to identify any abnormalities such as jaundice, edema, dehydration, cyanosis, anemia, and lymphadenopathy. Document findings in the patient file.
Inform the doctor about the patient’s condition and prepare for any required investigations and medical treatments.
Carry out procedures, such as tepid sponging, based on the patient’s findings (e.g., in case of high fever).

Investigations:

Conduct necessary investigations to rule out other diseases, such as:
- Blood slide for malaria parasites
- Full blood count (FBC) to rule out other infections
- Urinalysis
- Salivary measles-specific IgA testing (rarely done).

Medical Treatments:

There is no specific treatment for measles; it is managed symptomatically.
Prescribe the following drugs based on symptoms:
- Antibiotics to treat underlying infections (e.g., Cephalexin or Amoxyl syrup).
- Intravenous Ceftriaxone for severe cases.
- Analgesics to reduce pain and fever (e.g., Syrup Cetamol).
- Antihistamines to reduce itching (e.g., Calamine lotion).
- Vitamins A capsules for children below 1 year to prevent eye complications.
- Grovit drops or syrup multivitamin to improve appetite.

Fluids and Diet:

Provide plenty of oral fluids to replace lost fluids due to vomiting and diarrhea.
Offer easily digestible foods rich in vitamins and proteins for quick recovery.
Encourage the child to take frequent small meals.
Use a nasogastric tube for feeding if the child cannot eat or drink.
Administer intravenous fluids in cases of severe dehydration.

Skin Care:

Pad the fingers to prevent excessive scratching of the skin.
Apply prescribed calamine lotion to relieve itching.

Mouth and Eye Care:

Emphasize oral hygiene with frequent mouth care using warm saline.
Keep the nostrils clean and maintain cleanliness around the nasogastric tube.
Apply gentian violet 1% for mouth ulcers.
Use glycerin borax to lubricate the lips and prevent cracking.
Clean the eyes with warm saline and avoid rubbing them.
Apply TEO ointment if necessary.
If one eye is affected, encourage the child to lie on the affected side to prevent infecting the other eye.
Avoid direct sunlight on the eyes.

Hygiene and Bed Rest:

Give the patient a daily bath and change bedding frequently.
Use appropriate precautions for discharging ears and administer antibiotics as needed.
Disinfect used soiled linen and utensils.
Properly dispose of used swabs, discharges, or secretions.

Visitor and Ward Management:

Restrict visitors and maintain visiting hours.
Keep radio and TV volumes low to allow for patient rest.
Encourage dim lighting due to photophobia.
Encourage adequate sleep by switching off lights and minimizing noise.

Observations:

Continue monitoring the patient’s general condition and vital signs regularly.
Take note of any deviations from the normal and act accordingly.
Perform tepid sponging, give cold drinks, and apply cold compress on the forehead if the temperature is very high.

Bowel and Bladder Care:

Observe and treat diarrhea or constipation as needed.
Monitor and address any issues with the child’s urine output.

Exercises and Health Education:

Encourage the patient to do active and passive exercises, including deep breathing exercises.
Stimulate the child’s mind with play objects like toys.
Educate the mother/caregiver about the mode of spread, signs, symptoms, and prevention of measles.

Complications of Measles:

Measles can lead to various complications, some of which can be severe and life-threatening, especially in young children and immunocompromised individuals.

Respiratory System:

Laryngitis: Inflammation of the larynx, characterized by hoarseness and difficulty breathing.
Croup: A viral infection affecting the upper airway, resulting in a characteristic barking cough and stridor (a high-pitched whistling sound during breathing).
Bronchitis: Inflammation of the bronchi, causing coughing, wheezing, and difficulty breathing.
Pneumonia: Infection of the lungs, a leading cause of measles-related mortality. This can be caused by either the measles virus itself (primary viral pneumonia) or by secondary bacterial infections.
Bronchiectasis: Permanent widening of the bronchi, leading to chronic coughing and mucus production.

Central Nervous System (CNS):

Encephalitis: Inflammation of the brain, a rare but serious complication.
Mental Retardation: Long-term cognitive impairment, potentially a consequence of encephalitis.
Epilepsy: A neurological disorder characterized by recurrent seizures.

Gastrointestinal (GIT):

Gastroenteritis: Inflammation of the stomach and intestines, causing diarrhoea, vomiting, and abdominal pain.
Hepatitis: Inflammation of the liver, potentially leading to jaundice and liver dysfunction.
Mesenteric Adenitis: Inflammation of the lymph nodes in the mesentery, a fold of tissue that supports the intestines.
Appendicitis: Inflammation of the appendix, requiring surgical intervention.
Ileocolitis: Inflammation of the ileum (lower part of the small intestine) and colon.

Ear, Nose, and Throat (ENT):

Otitis Media: Infection of the middle ear, leading to ear pain, fever, and hearing loss.
Corneal Ulceration: Ulcers on the cornea of the eye, potentially causing vision impairment.

Others/Rare:

Myocarditis: Inflammation of the heart muscle, affecting heart function.
Glomerulonephritis: Inflammation of the kidneys, potentially leading to kidney failure.
Exacerbation of Tuberculosis (TB): Measles can reactivate latent tuberculosis infection due to compromised immunity.

Test Questions

MCQ: Which virus causes measles?
a) Influenza virus
b) Morbillivirus
c) Respiratory syncytial virus
d) Rotavirus
Answer: b) Morbillivirus
Explanation: Measles is caused by the morbillivirus, a member of the Paramyxoviridae family.

MCQ: During which stage of measles does the characteristic red maculo-papular rash appear?
a) Incubation stage
b) Prodromal stage
c) Catarrhal stage
d) Convalescence stage
Answer: c) Catarrhal stage
Explanation: The characteristic red maculo-papular rash appears during the catarrhal or eruptive stage of measles.

MCQ: What is the primary aim of nursing care in managing measles?
a) To reduce the risk of bacterial infection
b) To relieve itching and rash discomfort
c) To prevent complications and dehydration
d) To administer specific antiviral medication
Answer: c) To prevent complications and dehydration
Explanation: The primary aim of nursing care in managing measles is to prevent complications and dehydration, as there is no specific antiviral medication for measles.

MCQ: Which symptom is part of the classic triad used for suspecting measles?
a) Fever
b) Cough
c) Diarrhea
d) Jaundice
Answer: b) Cough
Explanation: The classic triad for suspecting measles includes cough, conjunctivitis, and coryza (common cold).

MCQ: What is the incubation period for measles?
a) 2-5 days
b) 7-10 days
c) 10-14 days
d) 21-28 days
Answer: c) 10-14 days
Explanation: The incubation period for measles typically lasts from 10 to 14 days.

MCQ: Which vitamin is administered to prevent eye complications related to measles in children below one year?
a) Vitamin B
b) Vitamin C
c) Vitamin D
d) Vitamin A
Answer: d) Vitamin A
Explanation: Vitamin A capsules are administered to children below one year to prevent eye complications associated with measles.

MCQ: Which stage of measles is characterized by an abrupt onset of severe symptoms, including very high fever and photophobia?
a) Incubation stage
b) Prodromal stage
c) Catarrhal stage
d) Convalescence stage
Answer: c) Catarrhal stage
Explanation: The catarrhal or eruptive stage of measles is characterized by an abrupt onset of severe symptoms, including very high fever and photophobia.

MCQ: What is the primary mode of measles transmission?
a) Contact with contaminated food
b) Direct skin-to-skin contact with an infected person
c) Airborne droplets from an infected person’s respiratory secretions
d) Ingestion of contaminated water
Answer: c) Airborne droplets from an infected person’s respiratory secretions
Explanation: Measles is primarily transmitted through airborne droplets when an infected person coughs or sneezes.

MCQ: Which of the following is NOT a risk factor for measles?
a) Immunodeficiency in children
b) Travel to areas where measles is endemic
c) Malnutrition
d) Taking vitamin supplements
Answer: d) Taking vitamin supplements
Explanation: Immunodeficiency, travel to endemic areas, and malnutrition are risk factors for measles, but taking vitamin supplements is not directly associated with measles risk.

MCQ: Which stage of measles marks the beginning of improvement, characterized by skin desquamation and a decline in body temperature?
a) Incubation stage
b) Prodromal stage
c) Catarrhal stage
d) Convalescence stage
Answer: d) Convalescence stage
Explanation: The convalescence or recovery stage of measles marks the beginning of improvement, characterized by skin desquamation, a decline in body temperature, and the resolution of symptoms.

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Malaria

Malaria is an acute febrile illness caused by the Plasmodium parasite, which invades red blood cells (RBCs).

It is an infectious disease where parasitic protozoa of the genus Plasmodium multiply within RBCs, leading to a variety of clinical manifestations.

Aetiology:

Parasite: The causative agent of malaria is a protozoan parasite belonging to the genus Plasmodium. There are five species that infect humans:

Plasmodium falciparum: The most dangerous species, responsible for the majority of severe and fatal cases.
Plasmodium vivax: Causes benign tertian malaria (fever every 48 hours), but can cause serious complications in some cases.
Plasmodium ovale: Causes ovale malaria, similar to vivax malaria, but is less common.
Plasmodium malariae: Causes quartan malaria (fever every 72 hours). While typically less severe, can lead to chronic complications.
Plasmodium knowlesi: Primarily infects monkeys but can be transmitted to humans.

Vector: The parasite is transmitted to humans through the bite of an infected female Anopheles mosquito, also known as the “malaria mosquito.”

Incubation Period

The period between the mosquito bite and the onset of malarial illness usually ranges from one to three weeks (7 to 21 days).

However, certain types of malaria, such as P. vivax and P. ovale, may take much longer, up to eight to 10 months, to cause symptoms. These parasites remain dormant (inactive or hibernating) in the liver cells during this extended period.

Unfortunately, some dormant parasites may persist even after a patient recovers from malaria, leading to the possibility of relapsing malaria, wherein the patient may fall ill again.

Transmission:

Mosquito Bite: An infected female Anopheles mosquito bites a human and injects sporozoites (infective stage of the parasite) into the bloodstream.
Liver Stage: Sporozoites travel to the liver and invade liver cells, where they multiply asexually.
Blood Stage: After several days, the parasite enters the bloodstream as merozoites, invading red blood cells.
Blood Stage Multiplication: Merozoites multiply asexually within red blood cells, causing their rupture and releasing more merozoites.
Sexual Stage: Some parasites develop into gametocytes, the sexual stage.
Mosquito Ingestion: If a mosquito bites an infected human, it ingests gametocytes.
Mosquito Development: Inside the mosquito, gametocytes mature and fertilize, forming sporozoites.
Mosquito Transmission: The sporozoites migrate to the mosquito’s salivary glands, ready to infect another human.

Predisposing Factors:

Geographic Location: Malaria is endemic in tropical and subtropical regions with suitable mosquito breeding grounds.
Age: Children under five are at the highest risk of severe malaria.
Immune Status: People with weakened immune systems (e.g., due to HIV/AIDS or malnutrition) are more susceptible to severe disease.
Pregnancy: Pregnant women are more vulnerable to malaria, as the parasite can affect both mother and fetus.
Travel History: Travelers to malaria-endemic areas are at risk of acquiring the disease.
Genetic Factors: Some individuals possess genetic traits that provide some protection against malaria.

Signs and Symptoms of Malaria

Malaria manifests through a variety of signs and symptoms, with fever being the most prominent and characteristic feature. The fever in malaria follows an intermittent pattern, coming and going repeatedly. A typical malaria attack can be categorized into three phases:

1. The Cold Stage:

Sudden onset of intense chills, often accompanied by shivering.
Sensation of coldness throughout the body.

2. The Hot Stage:

Intense heat and feverish feeling.
High fever, reaching 104°F (40°C) or higher.
Headache, often severe and localized to the frontal region.
Muscle pain, aches and stiffness, particularly in the back and limbs.
Nausea and vomiting, especially during febrile episodes.

3. The Sweating Stage:

Profuse sweating, often accompanied by a sense of relief from symptoms.

Other Symptoms Include:

A. Uncomplicated Malaria

i. In children under 5 years:

High fever: Detected by clinical thermometer, by touch, or reported by the caregiver.
Rigors: Shivering or trembling associated with the fever.
Loss of appetite: Reduced frequency of feeding, especially noticeable with breastfeeding.
Weakness and inactivity: Decreased energy levels and reduced movement.
Lethargy: Drowsiness and sluggishness.
Vomiting and diarrhea: These symptoms may accompany the fever.

ii. In older children and adults:

Fever: Recurrent fever, often accompanied by chills, sweating, and other symptoms.
Loss of appetite: Decreased desire for food.
Nausea and vomiting: Feeling sick to the stomach and throwing up.
Headache: Severe pain in the head, often localized to the frontal region.
Joint pains: Aching and stiffness in the joints.
Muscle aches: Soreness and pain in the muscles.
Weakness and lethargy: General fatigue and lack of energy.

B. Complicated/ Severe Malaria (Cerebral Malaria)

i. In children 5 years and below:

Signs of uncomplicated malaria plus any of the following:

Convulsions: Seizures within the last 2 days or currently present.
Inability to breastfeed or drink: Difficulty or refusal to feed.
Vomiting everything: Persistent vomiting, even after small amounts of food or fluids.
Altered mental state: Drowsiness, dizziness, lethargy, unconsciousness.
Extreme weakness (prostration): Inability to move or sit up.
Severe respiratory distress/ dyspnea: Difficulty breathing, rapid breathing, or labored breathing.
Severe anemia: Pale skin, fatigue, and shortness of breath due to low red blood cell count.
Severe dehydration: Dry mouth, sunken eyes, decreased urine output.
Hepatosplenomegaly: Enlargement of the liver and spleen.
Hemolytic jaundice: Yellowing of the skin and eyes due to destruction of red blood cells.

ii. In children 5 years and above (adults):

Signs of uncomplicated malaria plus any of the following:

Mental confusion and hallucinations: Disorientation, delirium, or seeing things that aren’t there.
Unconsciousness: Loss of consciousness.
Extreme weakness (unable to stand without support): Severe weakness and inability to stand without assistance.

Illustration of the Malaria Parasite Life Cycle:

Malaria Parasite Life Cycle:

Infection begins when an infected female Anopheles mosquito bites a person, introducing Plasmodium sporozoites into the bloodstream.
The sporozoites swiftly move into the human liver.
Over the next 7 to 10 days, the sporozoites multiply asexually in liver cells, causing no noticeable symptoms.
The parasites, now in the form of merozoites, are released from liver cells and travel through the heart to the lungs, where they settle within lung capillaries. The vesicles eventually disintegrate, releasing merozoites into the blood phase of their development.
In the bloodstream, the merozoites invade red blood cells (erythrocytes) and undergo further multiplication until the cells burst. They then invade more erythrocytes, repeating this cycle and causing fever each time they break free and infect new blood cells.
Some of the infected blood cells deviate from the asexual multiplication cycle and instead develop into sexual forms of the parasite known as gametocytes, which circulate in the bloodstream.
When a mosquito bites a human, it ingests these gametocytes, which further mature into sexually active gametes within the mosquito.
The fertilized female gametes transform into mobile ookinetes that penetrate the mosquito’s midgut wall, forming oocysts on its exterior surface.
Inside the oocyst, numerous active sporozoites develop. Eventually, the oocyst bursts, releasing sporozoites into the mosquito’s body cavity, which then migrate to its salivary glands.
The cycle of human infection begins anew when the mosquito bites another person.

Diagnosis of Malaria

Diagnosing malaria involves considering the patient’s clinical signs and symptoms, which can be challenging due to the similarity of malaria symptoms with other diseases, including yellow fever, typhoid fever, respiratory tract infections, meningitis, otitis media, tonsillitis, skin sepsis, and measles.

1. Clinical Evaluation:

Signs and Symptoms: Assess the patient’s clinical presentation, including fever, chills, sweating, headache, muscle pain, weakness, and any other relevant symptoms.

2. Laboratory Tests:

Microscopy:

Blood Smear Examination (Malaria Parasite Smear – MPS): This is the gold standard for malaria diagnosis. A blood sample is stained and examined under a microscope to identify the presence of malaria parasites within red blood cells. This test also helps to determine the specific species of Plasmodium responsible for the infection.

Rapid Diagnostic Tests (RDTs):

RDTs are antigen-based tests that detect specific malaria proteins in the blood. These tests are rapid and can be performed in resource-limited settings, but they may not be as sensitive as microscopy.

Quantitative Buffy Coat Test (QBCT):

This test estimates the number of red blood cells infected with malaria parasites by examining a centrifuged capillary tube. It is a more sensitive method for detecting low parasite densities, but it requires specialized equipment.

Complete Blood Count (CBC):

CBC evaluates various blood components, including red blood cells. Anemia (low red blood cell count) is commonly seen in malaria.

Hemoglobin Estimation:

Measures the amount of hemoglobin in the blood. Hemoglobin levels can be significantly reduced in malaria due to parasite-induced red blood cell destruction.

Liver Function Tests (LFTs):

These tests assess liver health, as the malaria parasites initially multiply in the liver.

Blood Chemistry Panel:

A blood chemistry panel evaluates electrolytes, kidney function, and liver enzymes, providing a comprehensive picture of the patient’s overall health status.

Polymerase Chain Reaction (PCR):

PCR is a highly sensitive molecular technique that can detect the genetic material of malaria parasites in the blood. This is particularly useful for diagnosing low-level parasitemia and differentiating between various Plasmodium species.

Serological Tests:

Serological tests detect antibodies produced by the body in response to malaria infection. They are not typically used for initial diagnosis but can be helpful for determining past exposure to malaria.

Management of Malaria

Treatment of malaria depends on the type of Plasmodium species, the severity of the disease, and patient-specific factors such as age, pregnancy status, and drug tolerance. Management is categorized into:

Management Of Uncomplicated Malaria

The recommended first-line medication for uncomplicated malaria is Artemether/Lumefantrine (Coartem).
In case Artemether/Lumefantrine is unavailable, the first-line alternative treatment is Atesunate + Amodiaquine.
The recommended second-line medication is Dihydroartemisinin + Piperaquine (Duocotecxin).
If not available, Quinine tables can be used.

For uncomplicated malaria, artemisinin-based combination therapies (ACTs) are the recommended first-line treatment. ACTs combine two drugs with different mechanisms of action, ensuring the rapid clearance of parasites and preventing drug resistance.
Common ACTs include:

Artemether-lumefantrine (Coartem)
Artesunate-amodiaquine
Artemisinin-piperaquine
Dihydroartemisinin-piperaquine

First-Line Treatment:

Artemether (20mg) + Lumefantrine (120mg/tab) (Coartem):

Administer the first dose under health supervision.
Fatty meals (including milk) enhance absorption.
If vomiting occurs within 20 minutes of swallowing the drug, the dose should be repeated.
Coartem is effective against blood schizonts and gametocytes, especially P. falciparum.
Not recommended for pregnant women in their first trimester or children weighing less than 5 kg.
If ACTs are unavailable or contraindicated, alternatives like quinine or atovaquone-proguanil may be used.

Dosage Schedule for Coartem (Artemether + Lumefantrine):

Weight (kg)	Age	Day 1	Day 2	Day 3
5-14	4 months – 3 years	1 tab	1 tab	1 tab
15-24	3 – 7 years	2 tabs	2 tabs	2 tabs
25-34	7 – 12 years	3 tabs	3 tabs	3 tabs
>35	>12 years	4 tabs	4 tabs	4 tabs

Alternative First-Line Treatment:

Artesunate (50mg/tab) + Amodiaquine (153mg/tab)

Second-Line Treatment:

The recommended second-line medication is Dihydroartemisinin + Piperaquine (Duocotecxin). If not available,
Quinine Tablets (300mg/tab): Used if first-line treatment fails or is contraindicated (e.g., in pregnancy, children under 5 kg). Dosage depends on body weight.

Supportive Treatment

Antipyretics (Paracetamol): For fever reduction.
The dosage is ; Paracetamol – 10mg/kg body weight tds for 3 days.

AGE	NUMBER OF TABLETS/ MAX
2 months to 3 years	¼ to ¾
3 years to 7 years	1 to ½
7 years to 10 years	1 to 3
10 years to 15 years	1.5 to 4 ½
>15 years	2 to 6 tablets

Tepid sponging, fresh air, cold compress, fluids: To manage fever.
Nutrition: Light foods, plenty of fluids, and encouraging breastfeeding for infants.

Counseling And Health Education

Ensure the patient understands the cause of malaria and complies with the full course of treatment.
Educate on symptoms, the importance of completing treatment, and the need to consult a health worker if symptoms worsen or persist after two days.
Discuss prevention measures like sleeping under treated mosquito nets.

Treatment of Malaria

Treatment of Uncomplicated Malaria:

The recommended first-line medication for uncomplicated malaria is Artemether/Lumefantrine (Coartem).
In case Artemether/Lumefantrine is unavailable, the first-line alternative treatment is Atesunate + Amodiaquine.
The recommended second-line medication is Dihydroartemisinin + Piperaquine (Duocotecxin).

Treatment of Severe and Complicated Malaria:

Parenteral Artesunate is the recommended treatment for managing severe malaria in all patients.
In the absence of Artesunate, Parenteral Quinine or Artemether can be used as alternatives.

Treatment of Malaria in Pregnancy:

Uncomplicated malaria:
- First trimester: Quinine tablets 60mg 8hourly for 7 days.(if Quinine not available, ACT may be used)
- Second and third trimesters: First line, Dihydroartemisinin/Piperaquine 3 tablets(1080mg) once daily for 3 days. If no response, Quinine tablets.
Severe malaria in pregnancy should be treated with intravenous Artesunate 2.4mg/kg at 0, 12 and 24 hours, then once daily until mother can tolerate oral medication. Complete oral treatment with ACTs within 3 days.
Alternate first line: IM artemether 3.2 mg/kg loading dose then 1.6mg/Kg once daily until mother can tolerate oral medications. Complete ACTs within 3 days.
If artesunate or artemether not available, use Quinine 10mg/kg every 8 hours in Dextrose 5%.

Remember quinine is associated with an increased risk for hypoglycemia in late pregnancy.

Additional Treatment Measures:

Antipyretic to Reduce Body Temperature:

Paracetamol: 10mg/kg body weight every six hours in children, 1g 6-8 hourly in adults.
Tepid sponging or fanning can also be used to reduce fever.

Anticonvulsants:

Diazepam: 0.2mg/kg body weight intravenously or intramuscularly in adults.

Treat Detectable Causes of Convulsions:

For example, hypoglycemia can be managed with Dextrose administration.

Nursing Care:

Provide supportive care and symptomatic treatment, such as tepid sponging for fever.
Regularly observe temperature, pulse, respiration rate, and blood pressure. Record all observations.
Educate patients on personal protection, malaria prevention, and the importance of adhering to treatment.
Administer antiemetic medicine 30 minutes to 1 hour before antimalarial drugs if vomiting occurs.
Advise patients to rest for 1-2 hours after taking the medicine to avoid dizziness, vomiting, and hypotension.
Offer psychological support and comfort to patients.
Encourage a nourishing diet with plenty of oral fluids. In cases of difficulty in eating or drinking, consider passing a naso-gastric tube.
Monitor fluid intake and output and maintain a fluid balance chart.
Ensure proper patient and environmental hygiene.

Management of Severe Malaria (Cerebral Malaria)

This is a medical emergency requiring immediate and aggressive treatment.

A. At OPD/ Health Center Level:

i. Reception:

Welcome the patient and attendant: Establish a calm and supportive environment.

Resuscitative measures:

Establish an IV line: This is crucial for administering fluids and medications.
Infuse IV fluids: Use isotonic solutions like normal saline or Ringer’s lactate to raise blood pressure and combat dehydration.
Assess vital signs: Monitor heart rate, blood pressure, respiratory rate, and temperature.
Assess level of consciousness: Use the Glasgow Coma Scale (GCS) to assess the patient’s mental status.

ii. Urgent Treatment (First Aid Management):

Administer IM quinine: Inject 10mg/kg body weight of quinine intramuscularly (IM).

Control temperature: Use antipyretics like paracetamol (10mg/kg orally or per NGT).

Treat convulsions:

Rectal diazepam: Administer 5 to 10mg rectally for children.
IV diazepam: Use IV diazepam for adults.

Provide hydration:

Oral glucose: Administer via nasogastric tube (NGT) if the patient can swallow.
IV fluids: Infuse isotonic fluids to correct dehydration.

Counsel on transfer: Explain the urgency of transferring the patient to a higher level of care.

Write referral letter: Include the patient’s vital signs, medications administered, and the reason for referral.

NB: The patient’s well-being is paramount. Do everything possible to ensure safe and timely transport to a facility equipped to manage severe malaria.

B. At Health Center IV or Hospital Management:

i. Reception in Emergency Department/ Intensive Care Unit:

Assess briefly: Rapidly assess the patient’s condition, including vital signs, level of consciousness, and signs of respiratory distress.

Inform the doctor immediately: While simultaneously initiating resuscitative measures.

Resuscitation:

Airway management: Ensure a patent airway by clearing any obstruction.
Positioning: Place the patient in a comfortable position, typically supine with head slightly elevated.
IV line: Establish an IV line for fluid and medication administration.
Blood sample: Draw blood for:

Malaria parasite smear (B/S): For confirmation and species identification.
Hemoglobin (Hb) grouping and cross-matching: For blood transfusion if needed.

Hypertonic glucose: Administer a 50% dextrose bolus (0.5-1ml/kg in children, 30-50ml in adults) to treat potential hypoglycemia.

ii. Doctor’s Orders: Ensure the doctor’s orders are carried out promptly and effectively.

iii. Admission:

Admit to ICU/ Medical Ward: Select the appropriate unit based on the patient’s condition.

Equipment: Ensure the room is equipped with:

IV trays: For medication and fluid administration.
Oxygen apparatus: For oxygen therapy as needed.
Suction apparatus: For airway clearance.
Monitoring equipment: For continuous monitoring of vital signs.
Breathing equipment: Ventilator if needed.

Ventilation: Ensure the room is well-ventilated with fresh air.

Positioning: Maintain the patient in a comfortable and supportive position.

Oxygen therapy: Provide oxygen if the patient is dyspneic (having difficulty breathing) or anemic.

iv. Investigations:

Malaria parasite smear: Obtain a blood smear for confirmation and species identification.
Hemoglobin (Hb) grouping and cross-matching: Perform blood typing and cross-matching in preparation for potential transfusion.
Lumbar puncture (LP): Assist the physician in performing a lumbar puncture to rule out meningitis as a differential diagnosis.

v. Chemotherapy:

Intravenous quinine: Administer an intravenous infusion of quinine (10mg/kg body weight) in 5 to 10ml/kg of 5% glucose solution over 4 hours.

Avoid loading dose: Do not give a 20mg/kg loading dose as quinine can cause hypotension and hypoglycemia.
Maximum dose: Do not exceed the adult dose.

Dosage: Continue administering quinine at 10mg/kg every 8 hours until symptoms improve. After three doses, consider transitioning to oral quinine or a first-line artemisinin-based combination therapy (ACT) such as Coartem.

Anticonvulsants: Administer diazepam rectally (5 to 10mg PRN) or intramuscularly (IM 0.2mg/kg for children, 10mg for adults) for seizures.

Antipyretics- 10 mg/ kg orally or per NGT, 500 to 1000 mg (paracet); i.e 1 to 2 tabs. Adults tds. I.V fluids; oral fluids depending on the dehydration level.

Artemisinin-based combination therapy (ACT): After the initial quinine infusion, consider switching to an ACT like Coartem (artemether-lumefantrine) for continued treatment.

Dosage: Follow the specific dosage guidelines based on the patient’s weight and age.
Route: Administer orally, ensuring the patient swallows each tablet whole.
Duration: Continue for the recommended duration as per the treatment regimen.

Alternative ACTs: If Coartem is unavailable or not tolerated, other ACT options include:

Malarone: (atovaquone-proguanil)
Riamet: (artemether-piperaquine)
Asunapril: (artesunate-amodiaquine)

Other Anti-Malarials: Consider adding doxycycline (100mg twice daily for 7 days) if the patient has multidrug-resistant malaria or if the clinical response is poor.

Antifungal therapy: If there is suspicion of fungal infection (e.g., cryptococcal meningitis), initiate appropriate antifungal therapy, such as fluconazole.

Management of complications:

Cerebral edema:

Mannitol: Administer IV mannitol as a diuretic to reduce cerebral edema.
Corticosteroids: Consider using corticosteroids like dexamethasone to reduce inflammation.

Hypoglycemia: Monitor blood glucose levels regularly and administer IV dextrose if necessary.
Electrolyte imbalance: Monitor electrolyte levels and correct imbalances with appropriate solutions.
Hemoglobinuria: This may indicate severe hemolytic anemia. Consider blood transfusion if necessary.

vii. Supportive Care:

Oxygen therapy: Provide supplemental oxygen if the patient is hypoxic.
Fluids: Continue IV fluid administration to maintain adequate hydration.
Nutrition: Provide nutritional support via nasogastric tube (NGT) or parenteral nutrition if oral intake is inadequate.
Blood transfusion: Perform blood transfusion if necessary to manage anemia and maintain adequate blood volume.

viii. Monitoring:

Vital signs: Monitor heart rate, blood pressure, temperature, and respiratory rate frequently.
Level of consciousness: Continue to assess the patient’s GCS score regularly.
Blood glucose levels: Monitor blood glucose levels closely, especially if the patient is receiving intravenous glucose.
Electrolyte levels: Monitor electrolyte levels to detect and correct imbalances.

ix. Discharge:

Follow-up: Arrange for close follow-up with the doctor to monitor the patient’s progress and address any concerns.
Repeat blood smear: Perform a blood smear 2 weeks after completing treatment to ensure that the patient is no longer parasitemic.
Malaria prophylaxis: Advise the patient and family members about the importance of malaria prophylaxis if returning to a malaria-endemic area.

Complications of Malaria:

Impaired consciousness/coma
Severe anemia
Renal failure
Pulmonary edema
Acute respiratory distress syndrome
Shock
Spontaneous bleeding
Acidosis
Hemoglobinuria (hemoglobin in urine)
Jaundice
Repeated generalized convulsions.

TREATMENT OF COMPLICATIONS

a. Hypoglycemia:

Give glucose 50%:

Children: 0.5 to 1 ml/kg IV bolus (slowly).
Adults: 30 to 50 ml/kg IV bolus.
Dilute: Dilute glucose with an equal volume of water for injection when giving to children.

Follow-up:

Adults: Administer glucose 20 to 30 ml TDS for 3 or more doses after the initial dose.
Monitor: Monitor blood glucose frequently.
Ensure: The patient is feeding.

b. Acidosis (Loss of Electrolytes):

Give IV fluids:

Ringer’s Lactate: Alternate with 5% glucose solution.
Normal Saline (N/S): Alternate with 5% glucose solution.

c. Pulmonary Edema:

Regulate IV infusions: Adjust the rate of IV fluid administration.

Positioning: Prop the patient up in bed (high Fowler’s position).

Frusemide (Lasix):

Adults: 40 to 80 mg IV.
Children: 0.5 to 1.5 mg/kg body weight PRN.

d. Severe Anemia:

Blood Grouping and Cross-Matching: Perform blood typing and cross-matching for potential transfusion.
Blood Transfusion: Administer blood (plasma and cells) at a rate of 20 ml/kg.

e. Shock:

Criteria:

Systolic BP: Less than 80 mmHg.
Capillary refill: Slow, less than 2 seconds.

Management:

Positioning: Raise the foot of the bed.
Fluid Resuscitation: Administer normal saline by rapid infusion.
Fluid Maintenance: Maintain adequate fluid intake.
Assess Anemia: Check for anemia and consider blood transfusion if necessary.

f. Acute Renal Failure:

Assess Cause: Determine if oliguria is due to shock or dehydration.
Frusemide: Administer frusemide as in pulmonary edema (above).

g. Convulsions:

Refer to: Management of Severe Malaria (see previous sections).

h. Coma:

Intensive Care: The patient requires admission to an intensive care unit (ICU).

Management:

IV Drip: Maintain an IV line for fluid and medication administration.
Urinary Catheter: Place a urinary catheter for monitoring urine output.
Nasogastric Tube (NGT): Place an NGT for nutritional support if necessary.
Positioning: Turn the patient every 2 hours to prevent pressure sores.

i. Hyperpyrexia:

Antipyretics: Administer antipyretics, such as paracetamol or ibuprofen.

j. Hemoglobinuria (Blackwater Fever):

Management:

Investigate and treat the cause.
Discontinue the suspected drug.
Steroids: Administer steroids (e.g., hydrocortisone, prednisolone, dexamethasone).

NURSING CARE

Feeding:

IV fluids: Administer IV fluids as needed.
Oral fluids: Encourage oral fluid intake.
Diet: Provide a soft, bland diet.

Other Nursing Care:

Hygiene: Maintain good personal hygiene.
Counseling: Provide psychosocial support (psychotherapy).

OTHER COMPLICATIONS

Hemolytic Jaundice: A complication of severe malaria.
Intrauterine Fetal Death (in Pregnancy): Can occur in pregnant women with severe malaria.
Hepatosplenomegaly: Enlargement of the liver and spleen.

Prevention and Control of Malaria

Implement Effective Treatment and Prophylaxis:

Early diagnosis and prompt treatment are essential to eliminate parasites from the human population. Timely treatment helps prevent the spread of malaria.
Vulnerable groups, such as pregnant women, should receive chemoprophylaxis (preventive medication). The following drugs are used for this purpose: Chloroquine, Doxycycline, Mefloquine, and Primaquine.
All pregnant women should be provided with Intermittent Preventive Treatment (IPT) to protect both the mother and the unborn child from malaria.

Reduce Human-Mosquito Contact:

Encourage the use of insecticide-treated nets (ITNs) while sleeping to create a physical barrier between individuals and malaria-carrying mosquitoes.
Implement indoor residual spraying of dwellings with insecticides or use knockdown sprays to control adult mosquitoes within households.
Advise individuals to wear clothing that covers the arms and legs, and to use mosquito repellent coils and creams when sitting outdoors at night to prevent mosquito bites.

Control Breeding Sites:

Eliminate stagnant water collection sites where mosquitoes breed, such as empty cans/containers, potholes, old car tires, and plastic bags. This can be achieved through proper disposal, draining, or covering with soil.
Use insecticides to treat stagnant water bodies to destroy mosquito larvae, or employ biological methods such as introducing larvae-eating fish to these water sources.

Provide Public Health Education:

Conduct public health education campaigns to raise awareness about malaria prevention measures, including the use of mosquito nets, personal protection measures, and the importance of seeking early diagnosis and treatment.
Educate communities about the significance of eliminating breeding sites and promoting good environmental hygiene to reduce mosquito populations.

Test Questions.

What is the primary mode of transmission of malaria to humans?
a) Contaminated food and water
b) Contact with infected animals
c) Bites from female Anopheles mosquitoes
d) Airborne droplets from infected individuals
Answer: c) Bites from female Anopheles mosquitoes
Explanation: Female Anopheles mosquitoes transmit malaria by injecting malaria parasites (sporozoites) into the bloodstream during their bite.
Which diagnostic test is considered the gold standard for confirming malaria infection?

a) Rapid Diagnostic Test (RDT)
b) Polymerase Chain Reaction (PCR)
c) Complete Blood Count (CBC)
d) Blood smear examination
Answer: d) Blood smear examination

Explanation: The blood smear examination under a microscope is the classic and most widely used diagnostic test for malaria. It allows visualization of malaria parasites inside red blood cells, helping to identify the Plasmodium species and guide appropriate treatment.

What is the recommended first-line treatment for uncomplicated malaria?
a) Artemether/Lumefantrine (Coartem)
b) Dihydroartemisinin + Piperaquine (Duocotecxin)
c) Quinine tablets
d) Doxycycline
Answer: a) Artemether/Lumefantrine (Coartem)

Explanation: Artemether/Lumefantrine is the recommended first-line medicine for treating uncomplicated malaria cases.

Which antimalarial drug is used as chemoprophylaxis to protect vulnerable groups from malaria?
a) Paracetamol
b) Chloroquine
c) Artemether
d) Diazepam
Answer: b) Chloroquine

Explanation: Chloroquine is one of the drugs used for chemoprophylaxis to protect vulnerable groups, such as pregnant women, from contracting malaria.

What intervention can help reduce human-mosquito contact and prevent malaria transmission?
a) Wearing clothes that cover the arms and legs
b) Spraying dwellings with insecticides
c) Drinking boiled water
d) Applying sunscreen
Answer: a) Wearing clothes that cover the arms and legs

Explanation: Wearing clothes that cover the arms and legs can help reduce mosquito bites and lower the risk of malaria transmission.

In severe malaria cases, what is the recommended first-line treatment for all patients?
a) Parenteral Quinine
b) Parenteral Artesunate
c) Intramuscular Artemether
d) Parenteral Mefloquine
Answer: b) Parenteral Artesunate

Explanation: Parenteral Artesunate is the recommended first-line treatment for severe malaria in all patients.

How long is the incubation period for malaria?
a) 1-3 days
b) 1-3 weeks
c) 1-3 months
d) 1-3 years
Answer: b) 1-3 weeks

Explanation: The incubation period for malaria is usually 1-3 weeks (7 to 21 days) after the mosquito bite.

Which complication of malaria is characterized by the presence of hemoglobin in urine?
a) Severe anemia
b) Jaundice
c) Acidosis
d) Hemoglobinuria
Answer: d) Hemoglobinuria

Explanation: Hemoglobinuria is the presence of hemoglobin in urine, which can occur as a complication of malaria.

What method is used to control mosquito breeding sites and prevent malaria transmission?
a) Introducing larvae-eating fish
b) Using insect repellent coils
c) Administering antimalarial drugs
d) Fumigating dwellings with pesticides
Answer: a) Introducing larvae-eating fish

Explanation: Introducing larvae-eating fish to stagnant water bodies is a biological method used to control mosquito larvae and prevent malaria transmission.

How can midwifery students contribute to malaria prevention in pregnant women?
a) Administering chemoprophylaxis during pregnancy
b) Providing insecticide-treated nets to pregnant women
c) Educating pregnant women about personal protection measures
d) All of the above
Answer: d) All of the above

Explanation: Midwifery students can play a vital role in malaria prevention for pregnant women by administering chemoprophylaxis, distributing insecticide-treated nets, and educating them about personal protection measures against malaria.

Malaria Read More »

TYPHOID FEVER(Enteric fever)

Typhoid fever is an acute bacterial infection characterized by fever and is primarily spread through contaminated food and water.

Causes

Typhoid fever is caused by Salmonella typhi and Salmonella paratyphi A and B.

Enteric fever: A febrile inflammatory reaction due to the presence of bacteria in the intestines. Typhoid fever is a specific type of enteric fever caused by Salmonella Typhi.
Salmonellosis: A general term for infections caused by bacteria of the genus Salmonella. Typhoid fever is a specific type of salmonellosis caused by Salmonella Typhi.
Typhoid fever: A systemic infectious fever characterized by high fever, malaise, enteritis (inflammation of the intestines), rose-spot rash, and involvement of the lymphoid tissues (like the spleen). It is caused by the bacterium Salmonella Typhi.

Salmonella Typhi:

Classification: Salmonella Typhi belongs to the Enterobacteriaceae family, a group of bacteria commonly found in the intestines of mammals. They are flagellated (have hair-like structures for movement).

Characteristics:

Gram-negative: They stain pink when subjected to a Gram stain, a common diagnostic tool for bacteria.
Aerobic or facultatively aerobic: They can survive with or without oxygen.
Metabolism: They typically thrive at 37°C and utilize glucose and mannose for energy.
Antigens: Salmonella Typhi possess both cell wall antigens (O) and flagella antigens (H), which help them invade host cells.

Serological Testing: The serum (blood fluid) of infected patients can be used in agglutination tests, where the serum is mixed with specific antisera (antibodies) to detect the presence of O or H antigens.

Commensalism: Salmonella species are common commensals in the gastrointestinal tract (GIT) of poultry, domestic pets, birds, and humans. However, Salmonella Typhi is unique in that it only affects humans.

Predisposing Factors/Causes:

Inadequate hygiene: Poor handwashing after defecation/urination, especially in areas with inadequate sanitation, can lead to the spread of the bacteria.
Vectors: Flies, which can carry the bacteria on their bodies, can spread the infection.
Poor environmental hygiene: Lack of clean water, overcrowding, inadequate excreta disposal (lack of latrines) all contribute to the spread of typhoid fever.
Poor nutrition and poverty: Malnourished individuals and those living in poverty are more susceptible to infections, including typhoid fever.
Achlorhydria: Lack of stomach acid (HCl) can decrease the ability to kill the bacteria.
Schistosomiasis: This parasitic infection can compromise intestinal integrity, making it easier for bacteria to invade.
Homogenous sickle cell disease patients: Individuals with this genetic condition are more susceptible to infections.

Incidence:

Age group: Typhoid fever can affect individuals of any age, but the peak incidence is between 10 to 25 years. It is more common in women.
Dose of organisms:

A dose of 100,000 organisms can cause disease in 25% of individuals.
A dose of 1,000,000,000 organisms results in disease in 95% of cases.
Increasing the dose of bacteria generally leads to a shorter incubation period.
Gastric acidity (pH) plays a role in killing ingested bacteria, with low pH levels (more acidic) being more effective.

Incubation Period:

The incubation period for typhoid fever is usually 2 to 3 weeks.

Transmission

Typhoid fever is contracted by the ingestion of the bacteria in contaminated food or water.
Patients with acute illness can contaminate the surrounding water supply through stool, which contains a high concentration of the bacteria.
About 3-5% of patients become carriers of the bacteria after the acute illness. Some patients suffer a very mild illness that goes unrecognized, and these patients can become long-term carriers of the bacteria.
The bacteria multiply in the gallbladder, bile ducts, or liver and pass into the bowel.
The bacteria can survive for weeks in water or dried sewage.
The chronic carriers may have no symptoms and can be the source of new outbreaks of typhoid fever for many years.

Transmission Routes:

Contact with formites: Contact with objects contaminated with feces or urine from patients or carriers.
Flies: Flies can carry the bacteria and spread it through contact with food or surfaces.
Ingestion: The most common route of transmission is through ingestion of contaminated food or water.
Ano-oral transmission: Direct transmission from feces to mouth, especially prevalent in settings with high carrier rates, like prisons.

Signs and Symptoms of Typhoid Fever

Classically, the course of untreated typhoid fever is divided into four stages, each lasting approximately one week.

First week:

In the first week, there is a gradual rise in temperature (step-ladder fashion) accompanied by bradycardia, malaise, headache, generalized body aching, restlessness, and cough.
Epistaxis (nosebleeds) is observed in about a quarter of cases.
Abdominal pain may also be present.
Leukopenia, eosinopenia, and relative lymphocytosis are evident in blood tests.
The classic Widal test, used to detect antibodies against Salmonella, is negative in the first week, but blood culture reveals the presence of Salmonella typhi.
The payer patches of the distal end of the ileum are invaded by the bacillus and become inflamed, resulting in various manifestations such as slow pulse rate, severe persistent frontal headache, general malaise, anorexia, nausea, vomiting, intestinal upset (diarrhea and constipation), and depression of bone marrow.

Second week:

The payer patches form a slough (a layer of dead skin).
In the second week of the infection, the patient becomes severely ill with high fever, often reaching around 40°C (104°F), and bradycardia.
Delirium is common, characterized by a state of calmness or, at times, agitation.

Rose spots, which are pink spots, appear on the lower chest and abdomen in about one-third of patients.
The abdomen becomes distended and painful, especially in the right lower quadrant.
Diarrhea may occur, with stool appearing green and having a characteristic smell resembling pea soup. However, constipation can also be frequent.
The spleen and liver enlarge (hepatosplenomegaly) and become tender.
The Widal reaction shows strong positivity with anti-O and anti-H antibodies, while blood cultures may still be positive at this stage.
The tongue is coated with a brownish fur, and sordes indicate severe toxemia.
Dehydration becomes evident.

Third week:

In the third week of typhoid fever, several complications may arise:
- The slough separates, leaving deep ulcers in the intestines.
- Ulcers may erode blood vessels, leading to hemorrhage, or perforate the ileum, causing leakage of intestinal contents into the peritoneal cavity.
- The patient becomes extremely ill and toxic.
- Temperature remains very high and intermittent.
- Pulse becomes feeble.
- The patient lapses into a typhoid state, experiencing delirium and confusion.
- Twitching of limbs may occur due to loss of calcium in the diarrhea state.
- Carforragic picking may lead to clotting issues and blood-stained clothes.
- Tough dries and flurried lips are observed due to severe dehydration from profuse diarrhea.
- Signs of congestive cardiac failure (CCF) due to weakened myocardium may be present.
- The patient may experience coma every eight hours.
- Peritonitis, inflammation of the peritoneum, may occur.
By the end of the third week, the patient becomes emaciated, fever starts to subside, abdominal symptoms become more pronounced, and mental disturbances become prominent.

Fourth week:

The ulcers begin to heal through granulation.
At the beginning of the fourth week, the fever begins to decline, and the other symptoms gradually reduce as the patient’s temperature returns to normal.
Recovery is slow during this stage, and relapses are common.
If left untreated, typhoid fever can prove fatal in up to 25% of all cases.

To summarize;

Clinical Presentation:

Week 1 (Week of Onset):

Gradual onset: Symptoms typically develop gradually, but a sudden onset, especially with shivering and rigors (intense shaking chills), can occur in “paralytic typhoid.”
Progressive symptoms: Symptoms increase in severity over 3 to 4 days, often leading to bed rest.
Headache: A severe headache is common, accompanied by malaise, anorexia, limb pain, insomnia, and epistaxis (nosebleed).
Nausea and vomiting: The patient feels unwell, with nausea and vomiting.
Abdominal pain: Pain in the abdomen, often diffuse, with normal bowel movements or sounds initially. The abdomen may become distended with gas.
Constipation or diarrhea: Both constipation and diarrhea can occur.
Chest pain and cough: Chest pain and cough due to bronchitis are common.
Fever: The temperature rises steadily and remittently (fluctuates but does not return to normal) in a “step ladder” pattern, reaching 40-41°C within 24 to 48 hours. After a period of sustained fever, it starts to remit (decrease) at night and eventually resolves by lysis (gradual decrease).
Bradycardia: A slow pulse rate (70-90 bpm) is a classic sign of typhoid fever.
Splenomegaly and hepatomegaly: Enlargement of the spleen and liver.
Nerve deafness: Common in the first week.

Week 2 (Infective Week):

Ulceration and sloughing: Peyer’s patches ulcerate and slough off, and blood and necrotic tissue may be passed in the stool.
Sustained fever: The temperature remains high.
Increased pulse rate: The pulse rate increases while the volume decreases.
Abdominal distention and tenderness: The abdomen continues to distend and become tender, especially in the right iliac fossa (lower end of the ileum).
Offensive stool: The stool is foul-smelling and yellow, often described as having a “pea-soup” color.
Muscle aches: Muscle pain is prominent.
Rose spots: “Red-rose” spots appear on the chest and abdomen, usually starting around the 7th day and disappearing after 3 days.

Week 3 (Complications Week):

Increased toxaemia: Severe cases are marked by complications arising from increased toxaemia (toxins in the bloodstream), which spreads to various organs and systems.
Severe illness: The patient becomes very ill, confused, hallucinatory, and mentally apathetic, exhibiting carphologia (picking at the bedclothes).
Delirium: The patient develops moderate delirium.
Temperature falls by lysis: The temperature falls gradually.
Weak and rapid pulse: The pulse is weak and rapid, and the patient is anemic.
Dry mouth: The mouth is dry, the tongue turns brown, and halitosis (bad breath) is present.
Mouth ulcers: Ulcers develop on the gums and mouth.
Hot, dry, and jaundiced skin: The skin is hot, dry, and jaundiced.
Semiconsciousness: The patient may become semiconscious and incontinent of urine and stool.
Death: Death can occur in severe cases.

Week 4 (Recovery Week):

Convalescence: This is a period of gradual recovery.
Ulcer healing: The ulcers gradually granulate and heal between the 3rd and 5th week, usually without scar formation.
Improvement: The patient gradually improves, temperature returns to normal by lysis, and other symptoms subside.

Investigations for Typhoid Fever:

Stool Culture: Stool culture involves collecting a sample of the patient’s stool and incubating it under specific conditions to identify and isolate the causative bacteria, usually Salmonella typhi or Salmonella paratyphi. The presence of these bacteria in the stool confirms the diagnosis of typhoid fever.
Blood Culture: Blood sample is collected and cultured in a suitable medium to identify and isolate the bacteria causing typhoid fever. A blood culture is an effective method to confirm the diagnosis, especially in the early stages of the disease when stool cultures might be negative.
Widal Test: The Widal test is a serological test used to detect antibodies produced by the body in response to the infection by Salmonella typhi. The test measures the presence of specific antibodies, including anti-O and anti-H antibodies, in the patient’s blood. A positive Widal test suggests a recent or past infection with typhoid fever. However, it is important to note that the Widal test results should be interpreted cautiously, as false-positive results can occur due to cross-reactivity with other infections or previous vaccinations.

Additional Investigations (optional):

Polymerase Chain Reaction (PCR) Test: PCR is a molecular diagnostic test that can detect the genetic material (DNA or RNA) of the Salmonella bacteria directly from clinical samples, such as blood or stool. PCR is a highly sensitive and specific method, and it can provide rapid results, aiding in early detection and timely treatment of typhoid fever.
Typhoid Serology: Typhoid serology involves analyzing the patient’s blood for specific antibodies against Salmonella typhi. This test, similar to the Widal test, helps in confirming a recent or past infection, but it may have limitations in terms of sensitivity and specificity.
Complete Blood Count (CBC): A CBC is a routine blood test that provides information about the number and types of blood cells. In typhoid fever, the CBC may show leucopenia (low white blood cell count), eosinopenia (low eosinophil count), and relative lymphocytosis (increased lymphocyte percentage). These abnormalities can help in supporting the diagnosis of typhoid fever.
Liver Function Tests (LFTs): Liver function tests assess the health of the liver and its ability to function properly. In typhoid fever, liver involvement is common, and LFTs can reveal elevated liver enzymes and other liver-related abnormalities.
Urinalysis: Urinalysis may be performed to check for the presence of white blood cells or other indicators of kidney involvement, which can occur in severe cases of typhoid fever.

Complications of Typhoid Fever:

I. Gastrointestinal Complications:
A. Perforation: The ulcerated areas in the intestines can lead to perforation, causing leakage of intestinal contents into the abdominal cavity. This can result in severe abdominal pain and peritonitis.
B. Hemorrhage: The erosion of blood vessels by ulcers can cause gastrointestinal bleeding, leading to blood loss and anemia.
C. Peritonitis: Perforation of the intestine can lead to peritonitis, an inflammation of the peritoneum (the lining of the abdominal cavity), causing severe abdominal pain and tenderness.

II. Gallbladder Complications:
A. Cholecystitis: The infection can spread to the gallbladder, causing inflammation known as cholecystitis, which leads to abdominal pain, fever, and tenderness in the right upper abdomen.

III. Respiratory Complications:
A. Pneumonia: In severe cases, typhoid fever can lead to pneumonia, a lung infection characterized by fever, cough, and difficulty breathing.

IV. Cardiovascular Complications:
A. Heart Failure: Severe and untreated typhoid fever can put a strain on the heart, leading to congestive heart failure, a condition where the heart fails to pump blood effectively, resulting in fluid accumulation in the body.

V. Musculoskeletal Complications:
A. Osteomyelitis: In rare cases, typhoid fever bacteria can spread to the bones, causing osteomyelitis, which is an infection of the bone and bone marrow.

VI. Neurological Complications:
A. Encephalitis: Typhoid fever can lead to encephalitis, which is inflammation of the brain. This can cause symptoms such as headache, confusion, and altered mental state.

B. Meningitis: In some instances, the infection may also spread to the meninges, the protective membranes covering the brain and spinal cord, leading to meningitis.

C. Mental Confusion: During the advanced stages of the disease, mental confusion and delirium may occur due to the systemic effects of the infection on the central nervous system.

Management of Typhoid Fever

Hospital Admission:

In severe cases of typhoid fever, hospital admission is necessary to provide close monitoring and appropriate medical care.

Isolation or Barrier Nursing:

Patients with typhoid fever should be isolated or barrier nursed to prevent the spread of the infection to others.

Investigations:

Blood for Culture and Sensitivity (C/S) should be performed during the first week to identify the causative bacteria and determine its sensitivity to antibiotics.
Full Blood Sample (FBS) analysis will reveal low Hemoglobin (Hb) levels, low White Blood Cell (WBC) count, and an increased Erythrocyte Sedimentation Rate (ESR).
The Widal test can be done around 10/7 days after the onset of symptoms to detect antibodies against typhoid bacilli.
Blood Smear (B/S) examination should be conducted to rule out malaria.
Stool analysis and urinalysis are important to assess gastrointestinal and urinary involvement in typhoid fever.

Drug Therapy:

Antibiotic therapy is a cornerstone of typhoid fever management:
- Ciprofloxacin at a dose of 500-750 mg twice daily for 10/7 (10 days).
- Azithromycin at a dose of 10 mg/kg daily.
- Cotrimoxazole at a dose of 960 mg twice daily for 3/7 (3 days) or as per a weight-based calculation for 10/7 (10 days).

Long-Term Carriers:

After signs have passed, stool tests should be conducted to check if Salmonella typhi bacilli are still present. Patients may become potential long-term carriers of the bacteria, requiring a 28-day course of antibiotics to eliminate the bacteria until they are free from it.

Fluid and Electrolyte Management:

Monitor intravenous (IV) fluid administration for rehydration.
Correct fluid and electrolyte imbalances with Normal Saline (N/S), Dextrose 5% (D5%) solutions, and oral fluids.

Nutrition:

Ensure adequate nutrition and provide a soft, easily digestible diet, unless the patient has abdominal complications or ileus.

Antipyretics:

Administer antipyretics like Paracetamol (PCM) to manage fever.

Hygiene and Infection Control:

Pay close attention to handwashing and limit close contact with individuals during the acute phase of the infection to prevent its spread.
Encourage proper waste disposal, covering of food, and proper food preparation to reduce contamination risks.
Encourage early screening and management to prevent the worsening of the disease.

Proper Water Treatment and Storage:

Educate patients on the proper treatment and storage of water to avoid waterborne transmission of the bacteria.

Regular Follow-Up and Monitoring:

Ensure regular follow-up and monitor for complications and clinical relapses.

Management of Delirium:

Encourage the use of Phenobarbital at a dose of 30-60 mg in case of delirium.

Treatment:

Antibiotic therapy:

Hospitalized patients: For hospitalized patients, treatment typically involves intravenous antibiotics, such as ceftriaxone or ciprofloxacin.
Hospitalized patients:

Ceftriaxone: 1-2 grams IV daily for 10-14 days.
Ciprofloxacin: 500-750mg IV twice daily for 10-14 days.

Non-hospitalized patients: For non-hospitalized patients with mild to moderate symptoms, oral antibiotics, such as ciprofloxacin or azithromycin, are often prescribed.
Non-hospitalized patients:

Ciprofloxacin: 500-750mg orally twice daily for 5-14 days.
Azithromycin: 500mg orally once daily for 3 days.

Supportive care: Provide supportive care, including:

Fluid replacement: Intravenous fluids or oral rehydration solutions are essential to prevent dehydration.
Pain management: Over-the-counter pain relievers can help manage pain and fever.
Nutritional support: Encourage adequate nutrition to support recovery.

Chronic Carriers:

Hospitalized patients: Hospitalized chronic carriers may require prolonged antibiotic therapy with medications like amoxicillin or ciprofloxacin.

Amoxicillin: 250mg orally three times daily for 4-6 weeks.
Ciprofloxacin: 500-750mg orally twice daily for 4-6 weeks.

Non-hospitalized patients: Non-hospitalized carriers may require ongoing monitoring and may be advised to avoid working in food-handling positions.

Immediate Nursing Care:

Rehydration: Provide intravenous fluids, nasogastric tube feeding, or oral rehydration solutions as needed to combat dehydration.
Temperature control: Implement tepid sponging and other measures to cool the patient’s temperature.
Hygiene: Maintain strict hygiene practices, including:

Skin care: Keep the patient’s skin clean and dry.
Mouth care: Provide oral hygiene to prevent mouth sores.
Nail care: Keep the patient’s nails trimmed and clean.
Perineal care: Keep the perineal area clean to prevent infection.

Personal protective equipment (PPE): Wear gloves, aprons, and goggles when handling anything from the patient to minimize exposure to bacteria.
Handwashing: Ensure frequent handwashing with soap and water and drying with clean towels.
Safe water and food: Use only treated or boiled water for drinking and cooking.
Disinfection: Dispose of wastes and excreta properly, disinfecting all contaminated items. Use disposable cups and plates whenever possible.
Non-disposable items: Disinfect non-disposable articles with concentrated disinfectants, replacing them regularly.
Linen treatment: Treat linens as infected material.
Terminal disinfection: Carry out terminal disinfection after the patient’s discharge.
Monitoring: Closely monitor the patient’s condition, particularly abdominal pain, diarrhea, constipation, and any signs of complications. Report any changes promptly.
Diet: Initially, provide a fluid diet high in calories, followed by a balanced, nutritious, soft diet (6-8 small meals).
Fluid and elimination: Monitor fluid intake and output, and assist with elimination as needed.
Psychological support: Offer emotional support to the patient.
Physiotherapy: Provide physiotherapy after the acute stage to help the patient regain strength and mobility.

Prevention:

Maintain cleanliness in the premises and ensure proper disposal of rubbish.
Keep hands clean and maintain trimmed fingernails.
Wash hands thoroughly with soap and water before eating or handling food and after using the toilet or changing diapers.
Drinking water should be free from microorganisms; it is preferable to boil water before consumption.
Avoid high-risk foods, such as raw or semi-cooked food.
During food preparation, wear clean, washable aprons, and caps.
Clean and wash food thoroughly, including scrubbing and rinsing fruits in clean water.
Store perishable food in the refrigerator, covering it properly.
Cook food thoroughly before consumption.
Consume food as soon as it is prepared.
If necessary, refrigerate cooked leftover food and consume it promptly. Reheat it thoroughly before consumption.
Exclude infected individuals and asymptomatic carriers from handling food and providing care to children.
Consider immunization, especially for those traveling to high-risk areas, where vaccines are available in oral and injectable forms.

Test MCQ Questions

Question 1:
What is the primary mode of transmission for typhoid fever?
A) Mosquito bites
B) Contaminated food and water
C) Airborne droplets
D) Direct physical contact

Question 2:
Which bacterium is responsible for causing typhoid fever?
A) Escherichia coli
B) Salmonella typhi
C) Streptococcus pneumoniae
D) Staphylococcus aureus

Question 3:
Which of the following complications can occur in severe cases of typhoid fever?
A) Fractures
B) Renal failure
C) Dental caries
D) Cholecystitis

Question 4:
Which diagnostic test is used to identify the presence of Salmonella typhi in the blood?
A) Blood smear examination
B) Stool culture
C) Urinalysis
D) Blood culture

Question 5:
What is the recommended antibiotic therapy for treating typhoid fever?
A) Penicillin
B) Amoxicillin
C) Ciprofloxacin
D) Erythromycin

Question 6:
Why is hospital admission often recommended in severe cases of typhoid fever?
A) To provide psychological support to the patient
B) To administer vaccines for long-term immunity
C) To ensure isolation and prevent disease transmission
D) To allow close monitoring and provide appropriate medical care

Question 7:
What is the primary preventive measure to avoid typhoid fever transmission in the community?
A) Proper handwashing with soap and water
B) Mosquito net usage
C) Wearing masks in public places
D) Vaccination against other bacterial infections

Question 8:
Which gastrointestinal complication can occur due to typhoid fever?
A) Pneumonia
B) Peritonitis
C) Otitis media
D) Conjunctivitis

Question 9:
Which of the following is NOT a recommended step to prevent typhoid fever?
A) Drinking untreated water from natural sources
B) Cooking food thoroughly
C) Washing hands properly before eating
D) Proper waste disposal

Question 10:
Who should be excluded from handling food and providing care to children during a typhoid fever outbreak?
A) Asymptomatic carriers and infected individuals
B) Healthcare professionals only
C) Pregnant women
D) Children under 5 years of age

Answers:

B – Contaminated food and water
B – Salmonella typhi
D – Cholecystitis
D – Blood culture
C – Ciprofloxacin
D – To allow close monitoring and provide appropriate medical care
A – Proper handwashing with soap and water
B – Peritonitis
A – Drinking untreated water from natural sources
A – Asymptomatic carriers and infected individuals

Explanation:

Typhoid fever is primarily spread through contaminated food and water, making option B the correct answer.
Salmonella typhi is the bacterium responsible for causing typhoid fever, making option B the correct answer.
Cholecystitis is one of the gastrointestinal complications associated with typhoid fever, making option D the correct answer.
Blood culture is used to identify the presence of Salmonella typhi in the blood, making option D the correct answer.
Ciprofloxacin is one of the recommended antibiotics for treating typhoid fever, making option C the correct answer.
Hospital admission is recommended in severe cases of typhoid fever for close monitoring and appropriate medical care, making option D the correct answer.
Proper handwashing with soap and water is the primary preventive measure to avoid typhoid fever transmission, making option A the correct answer.
Peritonitis is a gastrointestinal complication that can occur due to typhoid fever, making option B the correct answer.
Drinking untreated water from natural sources is NOT a recommended step to prevent typhoid fever, making option A the correct answer.
Asymptomatic carriers and infected individuals should be excluded from handling food and providing care to children during a typhoid fever outbreak, making option A the correct answer.

Typhoid Fever (Enteric Fever) Read More »

BACILLARY DYSENTERY (SHIGELLOSIS)

Bacillary dysentery, also known as shigellosis, is an acute diarrheal disease of the intestines characterized by the passage of blood-stained mucoid stool.

It is a local bowel wall infection and does not spread systematically.

It is important not to confuse bacillary dysentery with diarrhea caused by other bacterial infections, as one of the distinguishing characteristics of bacillary dysentery is the presence of blood in the stool, resulting from the invasion of the pathogen into the mucosa.

Cause:

The causative agent of bacillary dysentery is the bacterium Shigella. There are four main species:

Shigella flexneri
Shigella sonnei
Shigella dysenteriae
Shigella boydii

Shigella dysenteriae is considered the most virulent. These bacteria are strictly pathogenic to humans with no animal reservoir.

Shigella are non-motile, gram-negative bacilli found in the gastrointestinal tract (GIT). They cause disease by invasion and destruction of the colonic mucosa using exotoxins.

Sources of Infection:

Symptomatic patients: Individuals actively experiencing symptoms of shigellosis.
Carriers: Individuals who harbor Shigella bacteria but show no symptoms.

Infective Dose:

The infective dose varies. As few as 10 to 100 viable Shigella organisms can cause dysentery, but about 10,000 are required for other species.

Incidence:

Shigellosis affects all age groups, particularly in areas with poor sanitation. It is more prevalent in tropical countries and less developed nations.

Incubation Period:

The incubation period for shigellosis ranges 1-3 days (can extend up to 7 days). Pathology:

All Shigella species have the ability to invade and destroy the epithelial cells of the large intestines. They produce exotoxins with enterotoxic, cytotoxic, and neurotoxic properties.

Enterotoxins: Produce a secretory effect on the intestine, similar to that caused by cholera toxin, leading to watery (secretory) diarrhea.
Cytotoxin: Binds to the cell surface and is transported inside cells, inhibiting protein synthesis and causing cell necrosis, which results in dysentery.
Neurotoxin: May be responsible for neurological complications in children but not adults.

Transmission Routes (Oro-fecal Route):

Person-to-person contact: Finger-to-mouth transmission is the most important means of transmission, especially among household members where hygienic habits are lacking. The infection is also common where there is ano-oral sexual contact.
Water-borne: Contamination of water supplies by sewage and excreta containing Shigella leads to outbreaks of shigellosis in communities.
Food-borne: Contaminated food and milk products are major sources of infection in hospitals and communities. Shigella can survive in various foods for up to 30 days under favorable conditions.
Flies: Flies can transmit the bacteria by settling on dysenteric stool and then contaminating food or utensils.

Predisposing Factors.

Shigellosis is a bacterial infection that occurs when a person ingests Shigella bacteria, usually through contaminated food or water. The bacteria then multiply in the intestines and invade the lining of the colon, causing inflammation and ulceration.

Defective sanitation: Poor refuse disposal contributes to the spread.
Bad hygienic practices: Poor excreta disposal, dirty hands, skin, and clothes, and inadequate cleaning of the anal orifice facilitate transmission.
Heavy environmental infestation with flies: Flies act as mechanical vectors.
Wet environment with stagnating water areas: These environments promote the survival of Shigella.

Signs and Symptoms:

The severity of symptoms varies depending on the amount of toxin produced, the infective dose, and the type of Shigella.

Mild Type (Watery Diarrhea): Onset is gradual, with tenesmus (a painful effort to defecate) that causes straining and painful defecation lasting for a few days after abdominal discomfort and the passage of watery stool.
Moderate Type: Abrupt onset with abdominal pain, nausea, and vomiting. The passage of blood-stained mucoid stool. Gripping and tenesmus may be severe, with dysuria. High fever and rigor. The face is pinched, and the look is anxious. The patient may become delirious and confused. Marked thirst.
Fulminating Type (Very Severe): Abrupt onset as described above. Watery diarrhea that later becomes bloody and mucoid. The patient may pass stool as frequently as 10 to 20 times in 24 hours (muco-purulent stools). The motions then decrease, and dysentery symptoms set in. Necrotic sloughs may be passed out. Severe abdominal cramps. Tenesmus. Profound prostration due to fluid loss. Toxaemia occurs from toxin absorption into the circulation. The cheeks are flushed, the expression is anxious, the pulse is rapid, the tongue is coated yellow or dry and furred and brown. Marked dehydration with oliguria, dry, shriveled skin, collapsed veins, low blood pressure. The urine contains albumin. The patient is restless and may die in uraemic coma. Perforation and peritonitis may occur, although rare, with abdominal distension and hiccups.

Other clinical features include;

Bloody diarrhea: Frequent watery diarrhea, often containing blood and mucus.
Abdominal cramps: Intense cramping pain in the abdomen. Flatulence
Fever: High fever, often accompanied by chills.
Tenesmus: A feeling of incomplete bowel emptying, with frequent straining and urgency to defecate.
Nausea and vomiting: Can occur, especially in severe cases.
Headache: General malaise and weakness.
Dehydration: Significant fluid loss can lead to dehydration, especially in young children and the elderly.
Electrolyte imbalance: Diarrhea can cause significant electrolyte loss, leading to imbalances that can be life-threatening.
Rectal prolapse: In severe cases, especially in children, the rectum can protrude from the anus.

Diagnosis/Investigations:

Stool culture: The most definitive diagnostic test involves culturing stool samples to identify the specific Shigella species present.
Stool analysis and appearance/rectal swab: Microscopic examination of stool or rectal swab for Shigella bacteria.
Microscopic examination: Stool examination under a microscope may reveal red blood cells, white blood cells, and bacteria.
Serological tests: Serological tests can detect antibodies to Shigella bacteria in the blood.

Differential Diagnosis:

Cholera: Similar symptoms, but cholera is usually more severe.
Acute diarrhea from food poisoning: Caused by different bacteria or toxins.
Amoebiasis: Caused by a protozoan parasite.
Ulcerative colitis: A chronic inflammatory disease of the colon.
Schistosomiasis from Schistosoma mansoni: Caused by a parasitic worm.
Carcinoma of the colon and rectum: Cancer of the colon or rectum.

Management:

Aims:

Prevent the spread of infection: Implement infection control measures.
Preserve and save the patient’s life: Prioritize life support.
Support patient recovery (nursing care): Provide supportive care.
Eliminate the offending bacteria (treatment): Administer antibiotics.

Management depends on the severity of the condition. Severe cases caused by Shigella dysenteriae are considered medical emergencies.

Severe Type of Dysentery (Medical Emergency):

First Aid Treatment:

The patient is received at the healthcare facility and assessed for airway, breathing, and circulation (ABCs).
Signs and symptoms of dehydration and anemia are assessed, and appropriate action is taken.
Brief history is taken, and observations are made. Pulse is checked. A doctor is called, and the patient is reviewed.
An intravenous (IV) line is established, and fluids such as glucose 50% (30 to 50 ml bolus), normal saline, or Ringer’s lactate (500 to 1000 ml) are connected to control blood pressure and correct electrolyte imbalance.
The patient and their attendant are reassured about hospital transfer and conditions.
The patient is referred to the hospital promptly.

Ward Management (Medical Emergency):

The patient is received and assessed with details from the initial healthcare facility report.
The patient is admitted in isolation, if possible. If not, high-level hygiene and infection control measures are put in place.
Disinfection of stool and vomitus with 1% sodium hypochlorite or other disinfectants.
Strict use of equipment and utensils only for that patient.
IV fluids are continued as per doctor’s orders.
Frequent monitoring of the patient (every 4 hours) for vital signs (including temperature, pulse, respiration, and blood pressure), signs and symptoms of dehydration, and signs and symptoms of anemia.
Immediate investigations are conducted:

Hemoglobin grouping and cross-matching for blood transfusions if needed.
Stool for analysis to identify the specific Shigella species.
Serum electrolytes to assess electrolyte balance.
Rectal swabs for bacterial culture.
Full blood count (FBC) and erythrocyte sedimentation rate (ESR).

Continuous Care in the Ward:

Patient’s personal and environmental hygiene: Similar to the management of cholera or typhoid fever.
Feeding: During the acute stages, a fluid diet is provided, followed by a soft, balanced, non-irritating, non-spiced, low-residue diet as the stool becomes more solid. Food hygiene is crucial.
Treatment:

Antibiotics: Nalidixic acid 1 mg every 6 hours for 5 days or ciprofloxacin 1 mg stat (immediately).
Pain killers: Paracetamol for children. Bactrim 24 mg/kg for children.

Vital signs and other assessments: Regular monitoring.
Nursing care: Provide supportive nursing care, including hygiene, comfort measures, and monitoring.
Urine and bowel care: Provide regular care and hygiene for the patient’s urinary and bowel functions.
Terminal disinfection: Thorough disinfection of the patient’s environment after discharge.

IMMEDIATE NURSING CARE:

Rehydration:

Intravenous fluids (e.g., Normal saline, Ringer’s lactate)
Oral rehydration solutions (e.g., ORS)

Hygiene:

Skin care: Keep the patient’s skin clean and dry.
Mouth care: Provide oral hygiene to prevent mouth sores.
Perineal care: Maintain meticulous perineal care to prevent skin breakdown.

Personal protective equipment (PPE):

Gloves, aprons, and goggles are worn when handling anything from the patient.

Handwashing: Frequent handwashing with soap and water and drying with clean towels.
Safe water and food: Use only treated or boiled water for drinking and cooking.
Disinfection: Dispose of wastes and excreta properly, disinfecting all contaminated items.
Linen treatment: Treat linens as infected material.
Terminal disinfection: Carry out terminal disinfection after the patient’s discharge.
Monitoring: Closely monitor the patient’s condition, particularly abdominal pain, diarrhea, constipation, and any signs of complications. Report any changes promptly.
Diet:

Initially, provide a clear liquid diet, avoiding dairy products.
Gradually transition to a bland diet, low in fiber, and avoiding spicy, fatty, and greasy foods.

ADVICE ON DISCHARGE:

Continue hydration: Maintain adequate fluid intake.
Handwashing: Continue frequent handwashing.
Avoid contact: Avoid close contact with others until fully recovered.
Follow-up: Schedule a follow-up appointment with their healthcare provider.

summary;

- Admission to a medical ward in isolation.
- Strict personal hygiene (barrier nursing) to prevent infecting others.
- Disinfection of the patient’s bed and other items used.
- Proper disposal of fecal matter and vomit into a pit latrine.
- Regular monitoring of temperature, pulse, respiration, blood pressure, hydration levels, and level of consciousness.
- Providing reassurance and support to the patient and relatives.
- Fluid intake maintenance using Oral Rehydration Solution (ORS) or intravenous fluids in severe cases.
- Antibiotic treatment with drugs like nalidixic acid or ciprofloxacin.
- Implementing a BRAT diet (bananas, rice, applesauce, toast) to aid in recovery.
- Use of a nasogastric tube for feeding and medication administration if oral intake is not possible.
- Medications for managing nausea and vomiting, such as metoclopramide (plasil).
- Close monitoring of hydration levels and maintenance of a fluid balance chart.

Prevention:

- Maintain cleanliness in premises and kitchen utensils.
- Proper disposal of rubbish.
- Practice proper hand hygiene before eating or handling food, and after using the toilet or changing diapers.
- Boil or treat drinking water.
- Avoid high-risk foods like shellfish, raw or semi-cooked food.
- Use clean washable aprons and caps during food preparation.
- Thoroughly clean and wash food items, including fruits, in clean water.
- Store perishable food in a well-covered refrigerator.
- Ensure thorough cooking of food before consumption.
- Consume food promptly or refrigerate leftovers and reheat thoroughly before eating.
- Exclude infected individuals and asymptomatic carriers from handling food or providing care to children.

Complications:

Perforation: A hole in the intestinal wall.
Hemorrhoids and rectal prolapse: Occur due to over-straining during defecation.
Hemolytic-uremic syndrome (HUS): A serious complication that can occur with Shigella dysenteriae infection, leading to kidney failure.
Stricture of the colon: Narrowing of the colon after healing.
Post-dysenteric colitis (irritable bowel syndrome): Persistent passage of stool after recovery, with colicky abdominal pain, which may clear after 6 months but may be permanent.
Dehydration: Fluid loss due to diarrhea.
Renal failure: Kidney dysfunction.
Shock (Hypovolemic): Low blood pressure due to fluid loss.
Severe intestinal hemorrhage: Bleeding in the intestines.

Comparison between Bacillary and Amoebic Dysentery:

Feature	Bacillary Dysentery	Amoebic Dysentery
Occurrence	Epidemic	Endemic
Severity	“Lying down disease”	“Walking disease”
Onset	Acute	Gradual
Fever	Common	Unless complicated
Tenderness	Whole abdomen, especially sigmoid part	Localized to sigmoid colon
Quantity of Stool	Scanty but very frequent, bright red, colorless, viscid mucus, jelly-like	Much mingled with blood and mucus, offensive, smelling of decomposing blood, copious
Tenesmus	Very severe	Present but mild
Stool Microscopy	Numerous RBCs, WBCs, and macrophages; few bacteria	Many RBCs in clumps; WBCs and macrophages are scanty; large number of mobile protozoa
Cause	Bacterial	Protozoal
Complications	Toxic arthritis and eye complications	Hepatic and other abscesses; skin perforations

Amoebic Dysentery (Amoebiasis)

Amoebic dysentery is a parasitic infection of the gastrointestinal system that is caused by the parasite Entamoeba histolytica.

The infection is most commonly acquired through oral-fecal contamination, which can occur by consuming contaminated food or water, or by coming into contact with contaminated feces and not washing your hands properly.

Symptoms of amoebic dysentery

Violent diarrhea, often with blood and/or mucus in the stools
Severe colitis
Frequent flatulence
Dehydration
Abdominal cramps and tenderness
Slight weight loss
Moderate anemia
Moderate fever
Mild fatigue
Unrelated symptoms such as liver abscess, lung involvement, amoeboma swelling, and anal ulceration

Diagnosis

The diagnosis of amoebic dysentery is usually made by examining a stool sample under a microscope to look for cysts or motile organisms. Ultrasound scans may also be performed.

Treatment

The treatment of amoebic dysentery involves several steps:

Correcting any dehydration
Initiating a 10-day course of the antimicrobial drug metronidazole (Flagyl) or tinidazole to eliminate the infection
Administering amoebicidal (lumenal) drugs such as diloxanide furoate, paromomycin, or iodoquinol to eradicate any remaining parasites
Isolating infected individuals to prevent further spread of the infection
Emphasizing personal hygiene practices

Prevention

To prevent the occurrence and transmission of amoebic dysentery, the following preventive measures should be followed:

Educate the public about proper handwashing before eating and appropriate fecal disposal practices.
Ensure the proper management of carriers of the infection.
Promote the use of clean drinking water and safe food handling practices.

Dysentery Read More »

Cholera

Cholera is an infection of the small intestine caused by the bacterium Vibrio cholerae.

Cholera is a serious, acute intestinal diarrheal disease characterized by a sudden onset of profuse watery stools, severe vomiting, rapid dehydration, acidosis, and circulatory collapse.

If left untreated, death can occur within a few hours after the onset of symptoms. Cholera is an internationally notifiable disease, meaning it must be reported to authorities, and it can spread to any part of the world.

The infection is characterized by profuse watery stools, vomiting, dehydration, and collapse.

Cause

Vibrio cholerae: This comma-shaped, gram-negative bacterium is responsible for cholera. It is aerobic or facultatively anaerobic, motile (using flagella), and thrives in alkaline environments (pH 8.0). It grows best at 30-40°C, but dies in acidic media or at temperatures below or above this range.
This bacterium is Gram stain negative and possesses a flagellum, a long projecting part that enables it to move, and pili, hair-like structures that it uses to attach to the intestinal tissue.

Mode of Spread

Fecal-Oral Route: The most common route of transmission is through contaminated water and food, which occurs when feces from an infected person contaminate water sources or food.
Ingestion of Contaminated Food: Ingesting food contaminated with infected water can lead to infection.
Direct Contact: Direct contact with an infected person, particularly without proper hygiene, can transmit the disease.

Carriers: Carriers of the bacteria, even if they are asymptomatic, can spread the disease to others.

Susceptibility: Several factors influence the susceptibility to cholera:

Ingestion of bacteria: In a normal, healthy adult, approximately 100 million bacteria must typically be ingested to cause cholera. This highlights the importance of a significant bacterial load for infection to occur.
Age: Children, particularly those between the ages of two and four, are more susceptible to cholera infection. This could be attributed to their underdeveloped immune systems and increased likelihood of exposure due to their behavior and hygiene practices.
Lowered immunity: Individuals with weakened immune systems, such as those with AIDS or malnourished children, are at higher risk of experiencing severe cases if they become infected with cholera. Their compromised immune function makes it more difficult for their bodies to fight off the infection effectively.

Pathology

Intestinal Colonization: Vibrio cholerae colonizes the small intestine and multiplies rapidly.
Enterotoxin Production: Vibrio cholerae produces cholera toxin, which doesn’t invade the intestinal mucosa or enter the bloodstream.
Fluid Secretion: The toxin disrupts the normal function of intestinal epithelial cells, causing them to secrete large amounts of fluids and electrolytes into the intestinal lumen. This results in profuse watery diarrhea.
Dehydration: The loss of fluids and electrolytes leads to severe dehydration. The body tries to compensate by drawing fluids from other areas, leading to:

Dry Skin and Mucous Membranes: The skin becomes dry, and the mucous membranes (including the eyes, mouth, and tongue) become dry.
Thickening of Blood: Blood becomes more viscous due to fluid loss.
Collapsed Vessels: Blood vessels collapse due to low blood volume.
Muscle Cramps: Severe muscle cramps result from electrolyte loss.
Lung Failure: The lungs become dry and may fail due to dehydration.
Organ Failure: Other organs can fail as a result of severe dehydration and electrolyte imbalance.

Pathophysiology of Cholera

Cholera is a gastrointestinal illness caused by the bacterium Vibrio cholerae. The bacteria produce a toxin that causes the body to lose water and electrolytes, leading to severe diarrhea.

How the Bacteria Enter the Body

Most Vibrio cholerae bacteria are killed by the acidic environment of the stomach. However, a small number of bacteria can survive and travel to the small intestine. The bacteria attach to the intestinal wall and produce a toxin that causes the body to lose water and electrolytes.

The Toxin

The toxin produced by Vibrio cholerae is called cholera enterotoxin. The toxin binds to cells in the small intestine and activates an enzyme that causes the cells to pump water and electrolytes into the intestine. This results in the production of large amounts of watery diarrhea.

More Detailed Pathophysiology:
Upon consumption, most Vibrio cholerae bacteria do not survive the acidic conditions of the human stomach. However, a small number of bacteria manage to survive. As they exit the stomach and reach the small intestine, they need to navigate through the thick mucus lining in order to reach the intestinal walls, where they can establish themselves and multiply. Vibrio cholerae bacteria possess flagella for mobility and pili to attach to the intestinal tissue.

Vibrio cholerae bacteria produce a toxin that is responsible for causing the most severe symptoms of cholera. This toxin, known as an enterotoxin, acts on human cells, prompting them to extract water and electrolytes from the body, primarily from the upper gastrointestinal tract. The extracted fluid and electrolytes are then pumped into the intestinal lumen, resulting in the excretion of diarrheal fluid.

Clinical Picture/Signs and Symptoms

The incubation period for cholera is usually 2-3 days. The first signs and symptoms of cholera are watery diarrhea and vomiting. The diarrhea can be so profuse that it can lead to dehydration and shock.

In a typical case of severe cholera, the disease progresses through three stages:

First Stage (Diarrheal Stage)

Onset: This stage lasts for 3 to 12 hours.
Profuse, Watery Diarrhea: The hallmark of cholera is the sudden onset of watery diarrhea, which can be profuse, ranging from several liters to 10 liters per day. The stool resembles rice water, a thin, milky white fluid that may contain flecks of mucus.
Vomiting: Vomiting may be frequent and can be severe, further contributing to dehydration.
Muscle Cramps: Muscle cramps, particularly in the legs and abdomen, are common due to electrolyte loss.
Mild Dehydration: Initially, dehydration is mild, but it can progress rapidly if not addressed promptly.

Second Stage (Collapse Stage)

Rapid Dehydration: This stage develops within 6 to 12 hours.
Increased Fluid Loss: Diarrhea and vomiting worsen, leading to rapid fluid loss and severe dehydration.
Thirst and Weakness: Intense thirst and general weakness become prominent.
Sunken Eyes and Dry Mucous Membranes: As dehydration progresses, sunken eyes and dry mucous membranes (mouth, tongue, eyes) are evident.
Skin Turgor and Skin Elasticity: Skin becomes dry and wrinkled, and skin turgor (the ability of the skin to return to its original shape after being pinched) is decreased.
Hypovolemia (Low Blood Volume): The decrease in blood volume leads to a rapid heartbeat, low blood pressure, and a weak pulse.
Hypotension (Low Blood Pressure): Hypotension can be profound, and blood pressure becomes difficult to measure.
Rapid Breathing: The body compensates for fluid loss by increasing the respiratory rate.
Electrolyte Imbalance: Loss of electrolytes (sodium, potassium, chloride, bicarbonate) can cause muscle cramps, fatigue, and confusion.
Acidosis (Increased Acid in Blood): Dehydration can lead to metabolic acidosis, which can cause rapid breathing, confusion, and lethargy.
Hypoxia: Lack of oxygen to the brain due to reduced blood flow can cause lethargy, confusion, and coma.

Third Stage (Shock Stage)

Life-Threatening: This stage is life-threatening, and immediate medical intervention is essential.
Circulatory Collapse: Severe dehydration leads to a collapse of the circulatory system, resulting in shock.
Rapid Heartbeat: The heart races in an attempt to maintain blood pressure.
Weak Pulse: The pulse becomes weak and rapid.
Low Blood Pressure: Blood pressure drops significantly.
Altered Mental Status: Confusion, lethargy, and coma are common.
Kidney Failure: Dehydration can lead to kidney failure.
Respiratory Failure: Severe dehydration can cause respiratory failure.

Diagnosis of Cholera

The diagnosis of cholera is based on the following:

History: The patient may have a history of travel to an area where cholera is common, or they may have been in contact with someone who has cholera.
Symptoms: The patient will typically have watery diarrhea and vomiting. The diarrhea may be so profuse that it can lead to dehydration and shock.
Physical examination: The doctor will examine the patient for signs of dehydration, such as dry skin, sunken eyes, and decreased urination.
Laboratory tests: The following laboratory tests may be performed to diagnose cholera:
- Stool culture: This test is used to grow the bacteria in the laboratory.
- Polymerase chain reaction (PCR): This test is used to detect the genetic material of the bacteria.
- Rapid diagnostic test (RDT): This test is a rapid way to detect the bacteria.

Prevention of Cholera

Cholera is a serious disease that can be fatal, but it is preventable. The best way to prevent cholera is to follow proper sanitation practices.

Here are some specific steps you can take to prevent cholera:

Hand hygiene: Always wash hands with water and soap before preparing, serving, or consuming food. Additionally, it is important to wash hands with soap and water after using a latrine.
Safe drinking water: Boil all drinking water or treat it with chlorine. Store the treated water in a clean container to prevent recontamination.
Food safety: Consume food when it is still hot. If consuming raw foods such as fruits and vegetables, ensure they are properly washed, and when possible, peeled before eating.
Food storage: Cover all foods to prevent contamination by dust, house flies, and cockroaches.
Reporting and burial practices: In the unfortunate event of a cholera-related death, report it immediately to health authorities. Burial should take place promptly, and it is crucial to avoid serving food during this time.
Surveillance and reporting: Active surveillance and prompt reporting of suspected cases allow for the rapid containment of cholera epidemics.
Disinfection: Kill the germs by sprinkling germ-killing solutions, such as JIK, on stool or vomitus, as well as on any other materials used by the person suffering from cholera.
Water and sanitation improvement: Enhance water and sanitation infrastructure to reduce the transmission of infection, such as by improving access to clean water sources and implementing proper waste management systems.
Outbreak investigations: Conduct thorough investigations of diarrheal outbreaks to identify the source of contamination and implement appropriate control measures.
Cholera vaccination: Consider immunization with cholera vaccines in areas prone to outbreaks or for individuals at high risk of exposure.
Treatment of malnutrition: Address malnutrition, as individuals with weakened immune systems are more susceptible to severe cholera. Providing adequate nutrition can help improve their overall resilience.

Management and Treatment

Patient admission: The patient can be admitted to temporary hospitals, schools, or churches. Cholera beds with a central hole are used, allowing continuous stools to pass into a calibrated bucket containing a disinfectant.
Oral Rehydration Solution (ORS): ORS is the primary treatment for cholera. It is recommended for rehydrating patients and replenishing electrolytes lost through diarrhea. In cases of severe dehydration, intravenous Ringer’s lactate or normal saline, along with ORS, may be administered. The patient should be reassessed every one to two hours, and hydration should be continued. If there is no improvement in hydration, the intravenous drip rate may be increased. During the first 24 hours of treatment, the patient may require 200ml/kg or more of fluid. If hydration improves and the patient is able to drink, switching to ORS solution is recommended.
Nasogastric tube: In young children, a nasogastric tube can be used to administer fluids if necessary, ensuring adequate hydration.
Antibiotics: In certain cases, antibiotics may be prescribed. Doxycycline 300mg or ciprofloxacin as a single dose can be given, but they are contraindicated in pregnancy. For pregnant women, septrin can be used. In children, cotrimoxazole, doxycycline, ciprofloxacin, or erythromycin may be considered based on the specific circumstances.
Hypoglycemia management: If hypoglycemia is present, intravenous dextrose should be administered to correct low blood sugar levels.
Zinc supplementation: Zinc supplementation is effective in treating and preventing diarrhea, especially among children. It can be provided to aid in recovery.
Isolation and infection control: Patients should be isolated to prevent the spread of infection, as stools and vomit are highly infectious. Proper disposal of stools and vomit should be carried out, preferably into a pit latrine.
Equipment and instrument disinfection: Hospital equipment should be cleaned with a disinfectant such as JIK. Instruments can be cleaned with JIK or sterilized to prevent the transmission of the infection.
Fluid balance chart: A fluid balance chart should be instituted to monitor the patient’s hydration status closely.

Cholera Management:

Cholera is a medical emergency so prompt response should be initiated.

AIMS:

Immediate Reduction of Electrolyte and Fluid Loss: This is the primary goal, ensuring the patient’s survival.
Prevention of Infection Spread: Strict isolation measures are essential to prevent the spread of cholera within the healthcare setting and community.
Notification of Authorities: Promptly informing authorities about the outbreak is crucial for public health measures.
Elimination of Bacteria: Antibiotics are used to reduce the bacterial load and shorten the duration of illness.
Patient and Public Education: Raising awareness about cholera, its transmission, prevention, and proper management is essential for the community.

ACTIONS:

FIRST AID:

Reception: Properly protected healthcare personnel assess the patient’s airway, breathing, circulation (ABCs), signs and symptoms of dehydration (sunken eyes, dry mucous membranes, skin turgor), level of consciousness, and vital signs.
Immediate IV Line: Establish an intravenous line and begin fluid replacement with Ringers Lactate (R/L), Dextrose 5%, or Normal Saline, adjusting the rate according to the severity of dehydration.
Positioning and Oxygen: Place the patient in a comfortable position and provide oxygen therapy if necessary.
Hygiene: Ensure proper hygiene for the patient, including clean clothes, skin, and perineum.
History Taking: Gather detailed history, including the duration and severity of diarrhea and vomiting, level of consciousness, vital signs, and any relevant medical information.
Doctor’s Orders: Follow the doctor’s orders meticulously.
Treatment of Shock: Administer intravenous fluids as prescribed, usually starting with a rapid bolus of 100ml/kg over 30 minutes, followed by 70ml/kg over 2.5 hours. Reassess the patient’s response within 30 minutes to 1 hour. If there is no improvement, increase the rate of fluid administration.
Oxygen Therapy: Provide oxygen therapy as needed.

ADMISSION:

Isolation: Isolate the patient in a designated cholera bed with a central hole and bucket placed underneath for proper waste disposal.
Personal Protective Equipment: Healthcare personnel must wear appropriate personal protective equipment (PPE) when caring for the patient, including aprons, masks, isolation gowns, caps, gumboots, and disposable gloves. Explain the rationale for these measures to the patient.
District Health Authority: Inform the district health authority about the case for prompt public health action.

DRUGS:

Antibiotics:

Doxycycline: 300mg single dose OR
Ciprofloxacin: 1gm stat OR
Erythromycin: 62.5 to 250mg every 6 hours for 5 days OR
Ciprofloxacin: 20mg/kg single dose for children.

FREQUENT ASSESSMENT:

Vital Signs: Monitor vital signs every 15 minutes initially, then every 30 minutes, 1 hour, and 4 hours until discharge.
Dehydration Signs: Assess signs and symptoms of dehydration every 30 minutes, reclassify the severity, and adjust treatment accordingly.
Level of Consciousness: Observe the patient’s level of consciousness for signs of drowsiness, weakness, or confusion.
Fluid Output: Measure and record the volume, frequency, consistency, and characteristics of diarrhea and vomiting.

OTHER IMMEDIATE CARE:

Infection Control:

Disinfection: Disinfect all stool and vomitus with 1% sodium hypochlorite (JIK) before discarding.
Hygiene: Thoroughly clean and disinfect bedpans, buckets, urinals, and other contaminated items.
Patient Hygiene: Maintain patient hygiene by cleaning the skin, mouth, perineum, and providing padding as needed.
Linen Care: Soak contaminated linen in JIK for 2 to 6 hours, scrub thoroughly, place in labeled linen bags, and transport to the laundry for further disinfection.
Waste Disposal: Dispose of excreta and food remains after measurement and recordkeeping.
Utensil Care: Ensure the proper cleaning and disinfection of utensils.
Safe Water: Provide safe, boiled, and treated water for drinking and cooking.
Food Preparation: Ensure proper cooking of food and water treatment before consumption.
Environmental Hygiene: Thoroughly scrub sinks, equipment, and the patient’s room, labeling the room “Infectious, No Entry”.
Avoid Direct Contact: Minimize direct contact with patient’s waste.

DIET:

Parenteral Nutrition: Provide parenteral nutrition (IV or NG tube) in severe cases.
Fluid Diet: Start with a fluid diet (plenty of fluids) to rehydrate.
Light Diet: Gradually transition to a light, nourishing, well-balanced, non-irritating diet, considering the patient’s preferences and financial situation.
Normal Diet: Once the patient is stable, progress to a normal diet.

REHABILITATION/PHYSIOTHERAPY:

Passive ROM: Initiate passive range of motion exercises (ROM) while the patient is still in bed.
Active ROM: Encourage active sitting up in bed, moving to a chair, and walking around the room and outside for fresh air.
Reassurance: Continuously reassure the patient about their condition and their role in their recovery.
Health Teaching: Educate the patient about cholera:

Definition, causes, and mode of transmission
Importance of handwashing in infection control
Personal, community, and environmental sanitation or hygiene
Food and water hygiene and protection of water sources
Vector control using insecticide sprays
Reporting of new cases immediately
Mass screening, isolation, and treatment of suspected cases.
Limiting the use of equipment shared by infected individuals (showers, toilets, basins).

DISCHARGE:

Full Information: Discharge the patient with comprehensive information and follow-up dates.
Advice: Advise the patient on:

Adequate fluid intake
Good nutrition
Consumption of only safe food and water

Complications

Severe Dehydration and Vascular Collapse: This is the most serious complication of cholera, leading to circulatory shock and potentially death.
Electrolyte Imbalance and Acidosis: Severe fluid loss can disrupt electrolyte balance, leading to acidosis and potentially organ damage.
Shock: Dehydration can cause circulatory shock, a life-threatening condition.
Organ Failure: Dehydration and electrolyte imbalances can lead to heart, kidney, liver, and lung failure.
Hypoxia and Brain Malnutrition: Dehydration can cause hypoxia (lack of oxygen to the brain), leading to seizures, coma, and death.
Gangrene: Extreme fluid loss can lead to gangrene in the extremities due to reduced blood flow.
Hypostatic Pneumonia: Bedridden patients are at risk for hypostatic pneumonia due to reduced lung capacity.
Tetany: Electrolyte imbalances can lead to tetany, characterized by muscle spasms and seizures.
Acidosis: Dehydration and electrolyte imbalance can cause acidosis, a dangerous condition.
Abortion and Intrauterine Fetal Death: Severe diarrhea in pregnant women can increase intra-abdominal pressure, potentially leading to miscarriage or fetal death.

Prevention

Safe Water: Access to safe drinking water is crucial. Boiling water for 1 minute can kill Vibrio cholerae.
Handwashing: Frequent handwashing with soap and water, especially after using the toilet and before handling food, is essential.
Safe Food Handling: Proper food handling practices, such as cooking food thoroughly and storing it properly, can help prevent cholera.
Sanitation: Adequate sanitation facilities, such as latrines and sewage systems, are crucial for preventing the spread of cholera.
Vaccination: Oral cholera vaccines are available and provide partial protection against cholera infection. However, they are not always effective and require boosters for long-term protection.

Gastroenteritis (GE)

Gastroenteritis is a medical condition characterized by inflammation of the gastrointestinal tract that involves both the stomach (“gastro“-) and the small intestine (“entero“-), resulting in some combination of diarrhea, vomiting, and abdominal pain and cramping.

The severity of infectious gastroenteritis depends on the immune system’s ability to resist the infection.

Electrolytes (mainly sodium and potassium) may be lost as the infected individual vomits and experiences diarrhea.

Causes of Gastroenteritis

Viruses

Rotavirus, norovirus, adenovirus, and astrovirus are known to cause viral gastroenteritis.
Rotavirus is the most common cause of gastroenteritis in children.
Norovirus is the leading cause of gastroenteritis among adults, causing greater than 90% of outbreaks.

Bacteria

In the developed world Campylobacter jejuni is the primary cause of bacterial GE.
Escherichia coli
Salmonella, Shigella, and Campylobacter species.
Salmonella is contracted by ingesting the bacteria in contaminated food or water and by handling poultry.
Campylobacter occurs by the consumption of raw or undercooked poultry meat and other foods. It is also associated with unpasteurized milk or contaminated water.
Clostridium difficile is an important cause of diarrhea that occurs more often in the elderly. It is a common cause of diarrhea in those who are hospitalized and is frequently associated with antibiotic use.
Staphylococcus aureus infectious diarrhea may also occur in those who have used antibiotics.

Parasites

A number of protozoans can cause gastroenteritis – most commonly: – Giardia lamblia

– Entamoeba histolytica
– Cryptosporidium

Non-infectious causes

– Medications like NSAIDs
– Certain foods such as lactose (in those who are intolerant).
– Crohn’s disease.

Transmission:

The transmission of germs occurs through the feces or vomit of individuals infected with the illness. Gastroenteritis can be spread through the following means:

Consuming untreated or unboiled water from rivers, streams, lakes, ponds, or unprotected springs.
Eating cold food that has been exposed to dust, flies, or cockroaches.
Neglecting to wash hands with soap and water after using a latrine.
Eating unwashed fruits and vegetables.
Serving food and drinks in dirty containers.
Storing drinking water in unclean containers.
Improper disposal of feces.
Presence of open rubbish in areas that attract flies and cockroaches.

Signs and Symptoms:

The primary symptom is diarrhea, often accompanied by vomiting. Infected individuals may notice the presence of blood or mucus in their stools. Crampy abdominal pain is a common occurrence, which may temporarily ease after passing stool. There may be a low-grade fever, headache, and body aches. Symptoms of dehydration may include:

Muscular cramps, sunken eyes, decreased urine output, dry mouth and tongue, weakness, and irritability. In severe cases, adults may experience symptoms such as fatigue, dizziness or lightheadedness, headache, weakness, confusion, rapid heart rate, coma, and significantly reduced urine production.

Diagnosis:

Gastroenteritis is diagnosed clinically, based on a person’s signs and symptoms.
Stool cultures should be performed especially in those with blood in the stool.

Management:

Gastroenteritis is usually an acute and self-limiting disease that does not require medication.
The preferred treatment in those with mild to moderate dehydration is oral rehydration therapy (ORT).
Intravenous delivery may be required if there is a decreased level of consciousness or if dehydration is severe.
Plain water may be used if more specific and effective ORT preparations are unavailable or not palatable.
A nasogastric tube can be used in young children to administer fluids if necessary.
Institute a fluid balance chart.
Metoclopramide may be helpful in some children, and butylscopolamine is useful in treating abdominal pain.
Fermented milk products (such as yogurt) are similarly beneficial.
Zinc supplementation is effective in both treating and preventing diarrhea among children.
Antibiotics are not usually used for gastroenteritis, although they are sometimes recommended if symptoms are particularly severe or if a susceptible bacterial cause is isolated or suspected.
- If antibiotics are to be employed, a macrolide (such as azithromycin) is preferred. Metronidazole or Tinidazole is used if the cause is protozoa.
Isolation of the patient to prevent cross-infection.
Proper disinfection and disposal of stool and vomit.

Prevention and Control:

Always wash hands with water and soap before preparing, serving, or eating food.
Always wash hands with soap and water after using a latrine.
Boil all drinking water or treat it with chlorine. Store it in a clean container.
Consume food while it is still hot.
Ensure that raw foods such as fruits and vegetables are properly washed and, whenever possible, peeled before eating.
Cover all foods to prevent contamination by dust, house flies, and cockroaches.
In the event of a person’s death due to diarrhea, report it immediately to the health authorities.
Kill germs by using germ-killing solutions like JIK (bleach) on stool or vomit and on all other materials used by the person suffering from diarrhea.
Improve water and sanitation to reduce the transmission of infection.
Conduct investigations of diarrheal outbreaks.
Treat other infections such as typhoid, dysentery, etc.
Address and treat malnutrition.
Consider immunization with Rota vaccine, which provides protection against rotavirus, a common cause of gastroenteritis.

Gastroenteritis (GE) Read More »

Introduction to communicable diseases

Communicable diseases, also known as infectious diseases, pose a significant public health challenge in Africa, particularly among infants and children.

Communicable diseases are illnesses that can be spread from one person to another.

These diseases spread from person to person and, alongside malnutrition, are major contributors to illness and mortality on the continent. However, many of these diseases are preventable with proper interventions.

Communicable diseases, also known as infectious diseases or transmissible diseases are diseases that spreads from one person or animal to another or from a surface to a person.

Communicable diseases occur at all age groups outmost serious in childhood due to intensive exposure and poorly developed immunity. These diseases are to a great extent preventable

Tropical countries, Uganda, inclusive have continued to struggle with poverty related diseases that occur at an old age which include: diarrhea, parasite infestations, respiratory infections, immunizable childhood infections, eye infections and malnutrition. These countries are at the same time facing steady increase of diabetes, CVA, rheumatic conditions and cancer

Communicable’ diseases are divided into

Contact contagious diseases
STDs and HIV/AIDs
Vector borne diseases
Diseases related to contaminated water and food
Airborne diseases
Blood borne diseases
Diseases from the animals and their products
Helminthic diseases

Some Communicable diseases and there causative agents.

Causative Organism	Disease/Infection
Rabies virus	Rabies
Influenza A virus	Avian influenza (Bird flu)
Vibrio cholerae	Cholera
Plasmodium species	Malaria
Severe acute respiratory syndrome coronavirus (SARS-CoV)	Severe acute respiratory syndrome (SARS)
Trypanosoma species	Trypanosomiasis
Tsetse fly	Sleeping sickness (African trypanosomiasis)
Wuchereria bancrofti	Elephantiasis
Dracunculus medinensis	Guinea worm disease
Rotavirus	Diarrhea (caused by rotavirus)
Mumps virus	Mumps
Human immunodeficiency virus (HIV)	HIV/AIDS
Varicella-zoster virus	Chickenpox
Measles virus	Measles
Yellow fever virus	Yellow fever
Arboviruses	Arboviral diseases
African swine fever virus	African swine fever
Brucella species	Brucellosis
Salmonella enterica serovar Typhi	Typhoid fever
Schistosoma species	Schistosomiasis
Poliovirus	Poliomyelitis
Shigella species	Dysentery
Bacillus anthracis	Anthrax

Why are communicable diseases important in Africa?

Many of them are very common
Some of them are very serious and cause death and disability
Some of them cause widespread outbreaks of the disease- epidemics 4. Many of them are preventable by fairly simple means
Many are particularly serious and more common in infants and children.

Organisms and agents of disease

The living organisms that cause communicable diseases are of different sizes and sorts. The largest, like tape or filarial worms are visible to the eyes. They are made of many cells and are called metazoa.

Complicated but single celled organisms like malaria parasites and amoeba are called protozoa. They are smaller and can only be seen when magnified with a microscope. Smaller still are bacteria which are simple, single cell, best seen under a microscope after they have been stained with dyes.

Rickettsiae and chlamydiae are smaller and can only multiply within cells. Smallest of all are the viruses. These cannot be seen with an ordinary microscope.

Epidemiological Triad

Patterns of communicable diseases

Different diseases are common in different places and different times. To understand why this happens we need to consider the living organisms of disease- the agent; the people they infect the host and the surrounding in which they live- the environment.

The agents need a suitable environment in which to grow and multiply and must be able to spread and infect other hosts. If they do not succeed in doing this, they die out.

There is therefore a balance between the agent, the host and the environment which can change and be made to change in different ways.

Hosts (people) are affected by environment, for example, they may live in a hot climate in which there many mosquitoes. But people can also change this environment by draining swamps, changing the vegetation and adding competing hosts such as animals.

Similarly, the environment can affect the agent, for example, the altitude and the temperature for malaria.

Common Terms Used in Communicable Diseases:

1. Epidemic: A sudden increase in the number of cases of a disease in a particular region or population, exceeding the expected rate.

Example: The recent Ebola outbreak in the Democratic Republic of Congo was an epidemic, with a large number of cases occurring in a short period.

2. Endemic: A disease that is consistently present in a particular population at a stable rate.

Example: Malaria is endemic in many parts of Africa, particularly in tropical and subtropical regions, where mosquito vectors are prevalent.

3. Sporadic: Diseases that break out occasionally and irregularly.

Example: Smallpox was once a sporadic disease, but was eradicated through global vaccination programs.

4. Pandemic: Diseases that spread to several countries and affect a large number of people.

Example: The COVID-19 pandemic is a recent example, affecting almost every country in the world.

5. Isolation: Separation of persons with an infectious disease from those non-infected ones.

Example: Patients with tuberculosis are often isolated in special wards to prevent airborne transmission.

6. Period of Isolation: The length of time during which a patient with an infectious fever is considered capable of infecting others by contact.

Example: The period of isolation for measles is typically 14 days after the onset of rash.

7. Carriers: Individuals who harbour the bacteria or virus of a disease but are asymptomatic (show no symptoms).

Example: Typhoid Mary was a famous carrier of typhoid fever, unknowingly spreading the disease to many people.

8. Incubation Period: The period between the date of infection and appearance of symptoms of an infected person.

Example: The incubation period for HIV can range from a few weeks to several years.

9. Quarantine: Period of isolation of an infectious or suspected case to prevent the spread of the disease.

Example: Individuals who have been in contact with a confirmed Ebola case are often quarantined to monitor for symptoms.

10. Notifiable Diseases: Diseases that by law must be reported to the health authority.

Example: Ebola, SARS, and yellow fever are internationally notifiable diseases.

11. Pathology: The branch of medicine that deals with the essential nature of diseases, particularly the functional changes in tissues and organs caused by disease.

Example: Pathologists examine biopsies to identify the cause and progression of cancer.
African/Global Context: Strengthening pathology services is crucial for accurate diagnosis, treatment, and understanding of disease burden in Africa.

12. Aetiology: The study or science of the cause of diseases.

Example: Aetiology of tuberculosis includes infection with Mycobacterium tuberculosis bacteria.

13. Incidence: The number of particular new events which occur in a population in a given period of time (e.g., the number of new cases of a disease expressed per 1,000 population per year).

Example: According to WHO, Uganda has the world’s highest malaria incidence rate of 478 cases per 1,000 population per year.

14. Epidemiology: The study of the occurrence of diseases, including how and when they occur, how they are transmitted, etc.

Example: Epidemiologists investigate the causes of outbreaks of food poisoning to identify sources of contamination and prevent future occurrences.

15. Virulence: The ability of an organism to cause diseases.

Explanation: Virulence refers to the degree of pathogenicity (disease-causing ability) of a microorganism.
Example: The Ebola virus is highly virulent, leading to severe illness and high mortality rates.

The Transmission Cycle

Communicable diseases spread through different transmission cycles:

The transmission cycle of a disease refers to the process by which a pathogen (the causative agent) moves from an infected host to a susceptible host.

This cycle is useful for understanding the spread of infectious diseases and implementing effective control measures.

Elements of the Transmission Cycle:

Pathogen: The infectious agent, such as a virus, bacteria, parasite, or fungus, capable of causing disease.

Infected Host: The individual, human or animal, harboring the pathogen.

Exit: The method by which the pathogen leaves the infected host. This can occur through various routes, including:

Respiratory droplets: Expelled through coughing, sneezing, or talking.
Fecal-oral route: Excreted in feces and transmitted through contaminated food or water.
Bloodborne: Transmitted through blood or blood products.
Skin shedding: The pathogen is shed from the skin.

Transmission: The process of transferring the pathogen from the infected host to a susceptible host. Transmission mechanisms include:

Direct contact: Touching an infected individual or their secretions.
Indirect contact: Contact with contaminated objects or surfaces.
Airborne: Inhaling pathogen-containing droplets or particles.
Vector-borne: Transmission through an intermediate organism, such as an insect or animal.

Environment: The external surroundings where the pathogen may persist or survive.

Entry: The method by which the pathogen enters a susceptible host. This can occur through various portals, such as:

Respiratory tract: Inhalation of droplets or particles.
Gastrointestinal tract: Ingestion of contaminated food or water.
Skin: Penetration through breaks or wounds.
Mucous membranes: Through the eyes, nose, or mouth.

Susceptible Host: An individual who is at risk of infection due to factors such as:

Lack of immunity: No prior exposure to the pathogen or inadequate immune response.
Compromised immune system: Conditions that weaken the immune system.
Behavioral factors: Practices that increase exposure to the pathogen.

There are three parts of a transmission cycle for an agent or organism:

Source —-> Transmission —-> Susceptible Host

Source

The source of an infection can be an infected person or animal, or soil. People and animals may have clinical disease, subclinical disease or be carriers.

Transmission

The main routes of transmission are:

❖ Direct contact (skin, mucous membrane, sexual intercourse)
❖ Vector transmission
❖ Fecal contamination of soil, food and water which are ingested.
❖ Contact with animals or their products (e.g. biting)
❖ Airborne transmission (inhalation)
❖ Transplacental (mother to child) transmission
❖ Blood contact (injections, surgery, blood transfusion)

Susceptible Host

A susceptible host is one with low resistance to a particular infection. Low resistance may be due to:

Not having met the organism before and therefore not having any immunity to it. For example, at the age of 6-12 months, a child loses the passive immunity against measles which was acquired from the mother during pregnancy. When in contact with another child who has measles, the child will develop the disease because of no immunity against measles
Having another serious illness like AIDS at the same time. Such people have a higher risk of developing tuberculosis.
Malnutrition which can make the infection worse.

Principles of communicable disease control and prevention

The aim of control is to tip the balance against the agent. This may be done by:

Attacking the source
Interrupting route of transmission
Protecting the host

Attacking the Source	Interrupting Transmission	Protecting the Host
Treatment	Environmental sanitation	Immunization
Isolation	Personal hygiene	Chemoprophylaxis
Reservoir control	Vector control	Personal protection
Notification	Disinfection and sterilization	Better nutrition

Nursing Care of Patients with Infectious Diseases

Aims of Management

Promote recovery: Provide supportive care and interventions to facilitate healing and minimize complications.
Prevent further transmission: Implement infection control measures to limit the spread of the disease.
Maintain the patient’s quality of life: Address the physical, emotional, and social needs of the patient and family.

Initial Management

Reception: Providing a welcoming and supportive environment to reduce anxiety and establish a positive nurse-patient relationship.
Admission: Admitting patients to appropriate isolation wards or rooms to prevent further spread of the disease.
Positioning: Ensuring the patient is comfortable and supported based on their age and underlying condition.
Observations: Monitoring vital signs (temperature, pulse, respiration, blood pressure) and other relevant indicators to assess the patient’s condition.
Rest: Encouraging complete bed rest to promote recovery and minimize exertion.

Isolation and Barrier Nursing:

Isolation: Confining the patient to a designated area, such as a cubicle or corner of a ward, to prevent contact with other individuals.
Barrier Nursing: Employing techniques to isolate the patient and protect healthcare workers from potential infection:

Gloves: Wearing gloves when handling bodily fluids, dressings, or contaminated materials.
Aprons: Wearing aprons to protect clothing from contamination.
Masks: Wearing masks to prevent inhaling airborne pathogens.
Gowns: Wearing gowns to protect skin from contamination.
Disinfection: Using disinfectants to clean surfaces and equipment.
Sterilization: Using heat or chemicals to kill all microorganisms on instruments and supplies.

Diet and Nutritional Support:

Fluids: Providing adequate fluids to cool the body, replace lost fluids, dilute toxins, and facilitate excretion.
Fruit Juice: Supplying vitamin C to enhance appetite and support the immune system.
Proteins: Replacing worn-out tissues and cells for repair and recovery.
Carbohydrates and Fats: Providing energy and warmth for the body.
Diet Progression: Starting with fluids and gradually increasing food intake as the patient’s appetite and tolerance improve.

Skin and Pressure Sore Care:

Daily Bed Bath: Providing daily baths to maintain hygiene and prevent skin breakdown.
Pressure Area Treatment: Carefully assessing pressure areas (elbows, heels, sacrum) and implementing preventive measures to minimize the risk of pressure sores.

Mouth Care:

Regular Oral Hygiene: Providing regular oral care, including brushing, flossing, and mouthwashes, to maintain oral hygiene and prevent infections.

Other Essential Components of Care:

Exercises: Encouraging appropriate exercises based on the patient’s condition to maintain mobility and prevent complications.
Observations: Continuously monitoring the patient’s condition, including vital signs, behavior, and response to treatment.
Records: Maintaining accurate and detailed records of all observations, interventions, and progress.
Occupational Therapy: Collaborating with occupational therapists to provide customized interventions that help the patient regain functional abilities and adapt to limitations.
Emotional Support: Providing emotional support and empathy to the patient and family members, addressing concerns and offering reassurance.

Remember:

Patient Education: Educating the patient and family about the disease, its transmission, and preventive measures is crucial for long-term health and well-being.
Teamwork: Effective care for patients with infectious diseases requires a collaborative effort between nurses, physicians, other healthcare professionals, and the patient’s family.
Infection Control: Maintaining strict infection control measures is essential to prevent the spread of the disease to other individuals and healthcare workers.

Introduction to communicable diseases Read More »