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Chicken Pox

CHICKEN POX (Varicella-Zoster Virus)

Chickenpox (varicella) is a highly contagious viral infection caused by the varicella-zoster virus (VZV), a member of the Herpesviridae family.

It’s characterized by a pruritic (itchy) rash that progresses through macules (flat spots), papules (raised bumps), vesicles (fluid-filled blisters), pustules (pus-filled blisters), and finally crusts.

The colloquial name “Don’t Touch Me” reflects its contagious nature. The name “chicken pox” likely originates from the French “chich,” meaning chickpea, referring to the appearance of the vesicles.

Aetiology: VZV is a double-stranded DNA virus with an envelope. It’s transmitted via airborne droplets and direct contact with vesicle fluid.

Risk Groups:

  • Children under 10 years old (most commonly affected)
  • Immunocompromised individuals (those with weakened immune systems due to HIV, cancer, organ transplantation, etc.)
  • Pregnant women (risk of congenital varicella syndrome)
  • Adults who have not had chickenpox or the vaccine (risk of more severe illness)

Mode of Transmission:

  • Airborne: Inhalation of respiratory droplets from an infected person.
  • Direct contact: Touching the fluid from ruptured vesicles.
  • Indirect contact: Touching contaminated surfaces (fomites) then touching the eyes, nose, or mouth.

Epidemiology/Occurrence:

Chickenpox is globally prevalent, with most cases occurring in children. Mortality is very low, but scarring can occur, and these scars are susceptible to secondary bacterial infections. The infection typically confers lifelong immunity. However, the virus can remain latent in the nervous system and reactivate later in life, causing shingles (herpes zoster). This is especially likely in immunocompromised individuals or those with conditions like diabetes mellitus or leukemia.

Incubation Period: 10-21 days, averaging 14-16 days.

Pathogenesis:

The virus enters the body through the upper respiratory tract mucosa. Primary viremia (virus in the bloodstream) occurs, followed by secondary viremia, which disseminates the virus throughout the body. The virus then infects skin cells, causing the characteristic rash. The subcutaneous tissues and skin are primarily affected, with vesicle formation, rupture, and subsequent scarring during healing.

Signs and Symptoms:

  • Prodromal phase (1-2 days): Mild fever, headache, malaise, anorexia, body aches.
  • Maculopapular rash: Progresses to vesicles, pustules, and crusts. The rash is widespread, typically beginning on the face, scalp, and trunk, then spreading to the extremities. Different stages of lesions (macules, papules, vesicles, pustules, crusts) are often present concurrently.
  • Intense itching: A hallmark symptom.
  • Fever: Usually mild to moderate.
  • Lymphadenopathy: Swollen lymph nodes. (This is not explicitly mentioned in the provided text but is common).

Differential Diagnosis:

  • Impetigo
  • Multiple insect bites

Diagnosis

Diagnosis is primarily clinical, based on the characteristic rash and symptoms. Laboratory confirmation (viral culture, PCR, serology) might be done in ambiguous cases or for severe infections.

Management:

Aims:

  • Prevent spread of infection.
  • Prevent secondary bacterial infections.
  • Relieve symptoms (itching, pain, fever).
  • Prevent complications.

Actual Management:

  • Isolation: Strict isolation precautions are crucial to prevent spread until all lesions are crusted over (typically 5-7 days after rash onset). This includes contact precautions, airborne precautions (depending on local guidelines), and proper disposal of contaminated materials.
  • Skin care: Frequent bathing with lukewarm water, gentle patting dry, and application of calamine lotion or oatmeal baths to relieve itching. Keeping fingernails short is vital.
  • Medications:
  1. Antivirals: Acyclovir, valacyclovir, or famciclovir are recommended for high-risk individuals (adults, immunocompromised individuals, pregnant women) if started early in the course of the illness.
  2. Analgesics/Antipyretics: Acetaminophen (paracetamol) for fever and pain relief. NSAIDs (like ibuprofen) can be considered, but aspirin should be avoided due to the risk of Reye’s syndrome.
  3. Antihistamines: To help control itching.
  4. Topical corticosteroids: Might be used in severe cases to reduce inflammation, but this should be at the discretion of a doctor.
  5. Antibiotics: Only necessary if secondary bacterial infections develop.
  • Diet: Nutritious, well-balanced diet to support healing and recovery.
  • Supportive care: Ensuring adequate fluid intake, rest, and emotional support.

Symptomatic and Supportive Treatment:

  • Skin Care: Frequent bathing with lukewarm water, gentle patting dry, and application of calamine lotion every 12 hours or as needed. Cool, wet compresses can also provide relief from itching.
  • Antihistamines: To alleviate itching.
  1. Chlorpheniramine: Adults: 4 mg every 12 hours. Children under 5 years: 1-2 mg every 12 hours for a maximum of 3 days. (Always follow age-appropriate dosing guidelines; this information should be considered a general guideline only).
  • Analgesics/Antipyretics: Acetaminophen (paracetamol) for fever and pain relief. The dose is generally 10 mg/kg every 6 hours, but precise dosing should always be determined by a healthcare professional based on the child’s weight and age.
  • Antivirals: For adults and children over 12 years old, oral aciclovir 800 mg every 6 hours for 7 days may be considered, especially for severe cases or high-risk individuals. This decision should be made by a doctor, and early initiation is crucial for effectiveness.
  • Isolation: Keep the child home/away from school until all lesions are crusted over to prevent the spread of infection.

Complications:

  • Bacterial skin infections (impetigo, cellulitis): Most common complication resulting from scratching.
  • Pneumonia: VZV can directly infect the lungs.
  • Encephalitis: Rare but serious inflammation of the brain.
  • Hepatitis: Inflammation of the liver.
  • Myocarditis: Inflammation of the heart muscle.
  • Nephritis: Kidney inflammation (often due to secondary bacterial infection).
  • Congenital varicella syndrome: If a pregnant woman contracts chickenpox, particularly during the first 20 weeks of pregnancy, the fetus can suffer severe abnormalities.
  • Hemorrhagic chickenpox: Rare and severe, with bleeding into the skin.

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mumps (Parotitis)

MUMPS

Mumps, also known as epidemic parotitis, is an acute, contagious viral infection primarily affecting the salivary glands, most notably the parotid glands. 

Mumps is an acute, systemic, communicable viral infection. Its most characteristic feature is the painful swelling of one or both parotid glands. 

Aetiology:

Mumps is caused by the mumps virus (genus Rubulavirus, family Paramyxoviridae). This enveloped, single-stranded RNA virus is transmitted through respiratory droplets produced during coughing, sneezing, or talking by an infected individual. The virus replicates in the respiratory tract before spreading to other sites in the body, including salivary glands.

Forms and Routes of Transmission:

The primary mode of transmission is through direct contact with respiratory droplets from an infected person. This can occur through:

  • Droplet spread: Inhalation of aerosolized droplets expelled from an infected person.
  • Direct contact: Touching surfaces contaminated with respiratory secretions, and then touching the mouth, nose, or eyes. (This is less common than droplet spread).

Incubation Period:

The incubation period for mumps is usually 16–18 days (range 12–25 days), representing the time between infection and the onset of symptoms.

Clinical Features

Clinical Features :

  1. Prodromal Stage: Mild fever, malaise, and anorexia may precede other symptoms.
  2. Parotitis: Painful swelling of one or both parotid glands usually develops within 24 hours (though it can be delayed up to a week). Other salivary glands may also be affected. Swelling is accompanied by tenderness in the area between the earlobes and the mandibular angle. Patients often report earache, difficulty eating, and difficulty speaking. Glandular swelling increases for a few days and then gradually subsides, usually disappearing within a week.
  3. Orchitis: Most common in post-pubertal males, presenting as painful and tender enlargement of one or both testes. This can lead to testicular atrophy and potentially sterility.
  4. Oophoritis: In females, it causes lower abdominal pain (LAP).
  5. Mumps Pancreatitis: Causes abdominal pain, which can be difficult to diagnose.
  6. Mumps Encephalitis: Presents with high fever and marked changes in the level of consciousness.
  7. Parotitis: Painful swelling of one or both parotid glands (located below and in front of the ears). This is the hallmark feature of mumps. The swelling typically begins unilaterally but often becomes bilateral.
  8. Fever: Often high-grade (39-40°C or higher).
  9. Headache: A common and often severe symptom.
  10. Myalgia (muscle aches): Generalized muscle pain and stiffness.
  11. Malaise (general feeling of illness): Fatigue, weakness, and lack of energy.
  12. Anorexia (loss of appetite): Reduced or absent desire to eat.
  13. Nausea and vomiting: Occasional symptoms, particularly in children.
  14. Facial pain: This can be intense and localized to the affected salivary gland(s).
  15. Swelling of other salivary glands: Although less common, submandibular and sublingual glands can also be involved.
  16. Painful swallowing: Due to inflammation of the salivary glands and surrounding tissues.
  17. Dry mouth (xerostomia): From reduced salivary gland function.

Definitive Diagnosis and Investigations:

Diagnosis is primarily clinical, based on the characteristic swelling of the parotid glands and other symptoms. However, laboratory confirmation may be helpful, especially in atypical cases or suspected outbreaks. Tests include:

  • Serological tests: Detecting specific IgM and IgG antibodies against the mumps virus. IgM indicates acute infection, while IgG suggests past infection or immunity.
  • Viral culture: Less commonly used due to its lower sensitivity and longer turnaround time than serology.
  • PCR (polymerase chain reaction): Can detect the viral RNA in saliva or other specimens. This is a highly sensitive and specific method for

Management:

Aims:

  • Relieve symptoms.
  • Prevent complications.
  • Prevent spread of infection.

Medical Management:

There’s no specific antiviral treatment for mumps. Management focuses on supportive care:

  • Complete bed rest: Encourage rest to facilitate recovery.
  • Fever control: Antipyretics (e.g., acetaminophen) as needed.
  • Communication and feeding: Devise strategies to ensure effective communication and comfortable feeding, especially for those with difficulty swallowing.
  • Steroids (if prescribed): Corticosteroids (e.g., hydrocortisone 100-200 mg initially, followed by prednisolone 10-15 mg twice daily for 5-7 days) may be used to reduce inflammation in severe cases, but this is at the doctor’s prescription..
  • Anti-inflammatory medications: (In severe cases, corticosteroids are sometimes considered, but mainly if there’s severe complications)
  • Supportive care: Focuses on adequate rest, hydration, and pain management.
  • Hydration: Ensure adequate fluid intake to prevent dehydration. Offer fluids the patient can tolerate.
  • Pain relief: Acetaminophen (paracetamol) can be used to manage fever and pain and cold compresses. Avoid NSAIDs (like ibuprofen or aspirin) as these may increase the risk of bleeding.
  • Soft diet: Provide soft foods that are easy to swallow and minimize discomfort.
  • Oral hygiene: Encourage frequent rinsing of the mouth with warm salt water to soothe inflammation.
Prevention:
  • Vaccination: A live attenuated mumps vaccine ( part of the MMR vaccine) is highly effective in preventing mumps. It’s usually given subcutaneously in two doses, starting at 9 months or first contact, and at 18 months of age in Uganda.
  • Hygiene: Avoid sharing eating and drinking utensils with infected individuals.
Complications
  • Meningitis (inflammation of the meninges): The virus can spread to the brain, causing meningitis, with symptoms such as severe headache, stiff neck, fever, and altered mental status.
  • Encephalitis (inflammation of the brain): A rare but serious complication characterized by inflammation of the brain tissue.Symptoms can include seizures, coma, and lasting neurological deficits.
  • Orchitis (inflammation of the testicles): Common in post-pubertal males, causing testicular pain, swelling, and tenderness. While it can cause temporary discomfort and potentially impact fertility in severe cases, it usually resolves without long-term effects.
  • Oophoritis (inflammation of the ovaries): Rare complication in females, causing similar symptoms to orchitis, though usually less severe.
  • Deafness: Rare complication of mumps.
  • Pancreatitis (inflammation of the pancreas): Can lead to severe abdominal pain, nausea, and vomiting.
  • Myocarditis (inflammation of the heart muscle): Rare but potentially life-threatening complication.
  • Nephritis (inflammation of the kidneys): Rare and typically mild.

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Yellow fever

YELLOW FEVER

Yellow fever is an acute viral hemorrhagic disease transmitted by infected mosquitoes. 

Yellow fever is an acute, contagious, notifiable viral hemorrhagic fever endemic in central and South America and Africa.

The name derives from the jaundice (yellowing of the skin and eyes) that affects some patients. 

Aetiology:

Yellow fever is caused by the yellow fever virus (YFV), an arbovirus belonging to the Flavivirus genus of the Flaviviridae family. The virus is approximately 25-65 nm in size and can survive at 40°C for a month and in a freeze-dried state for many years.

Forms and Routes of Transmission:

The primary mode of transmission is through the bite of infected Aedes mosquitoes (primarily Aedes aegypti in urban areas and Aedes africanus in sylvatic/jungle cycles). These mosquitoes become infected when they feed on the blood of infected primates (monkeys, apes) or humans.

There are two main transmission cycles:

  • Sylvatic (Jungle) Cycle: This cycle involves transmission between monkeys and mosquitoes in forested areas. Humans can become infected through contact with this sylvatic cycle if they venture into these areas.
  • Urban Cycle: This cycle occurs in urban areas where Aedes aegypti mosquitoes are abundant and feed on both infected humans and other humans. This cycle is responsible for larger outbreaks.

Incubation Period:

The incubation period for yellow fever is typically 3 to 6 days, but can range from 2 to 15 days. This is the time between the bite of an infected mosquito and the onset of symptoms.

Pathology:

After entering the body through a mosquito bite, the virus multiplies in lymph nodes and organs (liver, kidneys, heart, lungs, spleen, brain, digestive tract). The virus primarily affects specialized epithelial or myocardial cells. Cellular changes range from cloudy swelling to generalized fatty changes, coagulation, and necrosis.

  • Liver: Destruction of epithelial cells in liver lobes.
  • Kidneys: Necrosis of tubular epithelium.
  • GIT: Hemorrhage due to damage of blood vessels.

Death can result from liver or kidney failure (or both). Damage to the sino-atrial node, bundle of His, and myocardial cells can also contribute.

YELLOW FEVER

Clinical Features

Yellow fever presents in two phases:

Phase 1 (Acute Phase): This phase usually lasts 3-4 days and includes:

  • Sudden onset of fever (often high, 38.3°C to 40°C or higher)
  • Severe headache
  • Muscle aches (particularly back pain)
  • Shivering
  • Nausea and vomiting
  • Loss of appetite
  • Fatigue
  • Malaise

Phase 2 (Toxic Phase): This phase doesn’t always occur and only develops in severe cases. It’s characterized by:

  • Jaundice (yellowing of the skin and whites of the eyes)
  • Bleeding (from the nose, mouth, or gums – hemorrhage)
  • Abdominal pain
  • Dark urine
  • Low blood pressure (hypotension)
  • Impaired kidney function
  • Delirium
  • Shock
  • Seizures

A short period of recovery may occur, followed by a return of fever and rapid deterioration with liver and kidney failure.

  • Continuous abdominal pain with vomiting of altered blood (“coffee ground” or fresh blood) or black vomit (melena), and potentially diarrhoea.
  • Bleeding from eyes, nose, mouth, bladder, rectum, and other organs.
  • Heavy proteinuria (protein in the urine) with oliguria (decreased urine output) and granular casts, red blood cells (RBCs), and haemoglobin (Hb) in the urine.
  • Death occurs with increasing proteinuria, haemorrhage, rising pulse, hypotension, and oliguria.

Diagnosis and Investigations:

Diagnosis is based on:

  • Clinical presentation: Symptoms are highly suggestive.
  • Serological tests: Detection of IgM antibodies in the blood using ELISA (enzyme-linked immunosorbent assay) or other methods indicates recent infection. LFT’s and RFT’s
  • Virus isolation: This can be performed from blood samples during the acute phase of illness, but is less commonly used due to the availability of serological testing.
  • PCR (Polymerase Chain Reaction): Detection of viral RNA in blood samples. This is a more sensitive technique for confirming diagnosis.

Management:

Aims:

The primary aims of management are:

  • To provide supportive care to manage symptoms.
  • To prevent complications.
  • To reduce mortality.

Medical Management:

No specific antiviral treatment is available for yellow fever. Management focuses on supportive care, including:

  • Fluid and electrolyte balance: Careful monitoring and replacement are crucial.
  • Respiratory support: Oxygen therapy as needed.
  • Blood pressure management: Vasopressors if needed.
  • Seizure control: Anticonvulsants as needed.
  • Monitoring for organ dysfunction: Close monitoring of kidney function, liver function and other organ systems is critical.
  • Nutritional support: Enteral or parenteral nutrition as necessary.

Nursing Care:

Nursing care is essential and focuses on:

  • Monitoring vital signs: Frequent monitoring of temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation.
  • Fluid balance management: Careful monitoring of fluid intake and output.
  • Neurological assessment: Regular neurological checks for signs of encephalopathy.
  • Skin assessment: Monitoring for jaundice and signs of bleeding.
  • Hygiene: Maintaining personal hygiene to prevent skin breakdown.
  • Pain management: Providing analgesics as needed.
  • Emotional support: Providing emotional support to the patient and their family.
Prevention:
  • Vaccination: The most effective preventive measure is vaccination. A single dose of the yellow fever vaccine provides lifelong protection.
  • Mosquito Control: Reducing mosquito breeding sites through eliminating standing water, using insecticides and using mosquito nets.
  • Personal Protective Measures: Wearing protective clothing (long sleeves, long pants) and using insect repellent containing DEET or other EPA-approved repellents when in endemic areas.
Complications:
  • Hepatitis: Liver inflammation can lead to liver failure.
  • Renal failure: Kidney damage can result in acute kidney injury or failure.
  • Encephalitis: Brain inflammation can lead to neurological deficits.
  • Myocarditis: Heart muscle inflammation.
  • Hemorrhagic manifestations: Severe bleeding can be life threatening.
  • Shock: This can be fatal if not promptly managed.
  • Death: Yellow fever can be fatal in a significant proportion of severe cases.

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EBOLA: HAEMORRHAGIC FEVERS

HAEMORRHAGIC FEVERS

Ebola and Marburg

  • Ebola and Marburg are severe zoonotic multisystem febrile diseases caused by RNA viruses. They are notifiable diseases.

Ebola Virus:

  • Morphology: The Ebola virus is filamentous, often resembling a “U” or “S” shape. It measures approximately 2 μm (micrometers) in length and 70-80 nm (nanometers) in diameter. It has an internal structure (nucleoprotein core) enclosed within an external envelope studded with numerous glycoprotein spikes.
  • Multiplication: The virus replicates by budding from its internal structures.

Types of Ebola Viruses:

Ebola Virus (EBOV): This is the species most commonly associated with severe outbreaks in humans.

  • EBO-Zaire (EBO-Z): This subtype has a high fatality rate, averaging around 89%.
  • EBO-Sudan (EBO-S): This subtype has a fatality rate of 41.65%, although this can vary depending on factors like treatment and location.

Vectors:

  • Mosquitoes and Termites: While there have been theories suggesting these insects could play a role in transmission, there is no definitive evidence to support their role as vectors for Ebola.
  • Bats: The most likely primary reservoir for Ebola viruses. They can harbor the virus without showing symptoms and transmit it to other animals or humans.
  • Dogs: While some sources mention dogs, there is no clear evidence to suggest they are a significant reservoir for Ebola.

Transmission:

Human-to-Human:

  • Direct contact with infected bodily fluids, such as blood, vomit, feces, urine, and saliva.
  • Contact with contaminated materials like clothing, bedding, needles, and medical equipment.
  • Sexual contact with a survivor who is still shedding the virus in semen (this can last for months after recovery).

Animal-to-Human: Contact with infected animals (particularly primates like chimpanzees and gorillas) or their bodily fluids.

Mosquitoes: As mentioned above, mosquitoes are not considered reliable vectors for Ebola virus transmission.

 

Pathology:

The Ebola virus affects multiple tissues throughout the body, not just a specific organ. It causes widespread damage, including:

  • Necrotic Lesions: The virus leads to cell death (necrosis) in various organs, affecting their functionality.
  • Immune System Suppression: Ebola weakens the immune system, making individuals vulnerable to other infections.

Incubation Period:

  • Primary Infection: The incubation period typically ranges from 2 to 21 days after exposure.
  • Secondary Infection: For transmission from human to human, the incubation period is the same, 2 to 21 days.

Causes:

Ebola Virus: The causative agent is the Ebola virus, a member of the Filoviridae family. There are five known species of Ebola virus:

  • Zaire ebolavirus (responsible for the most severe outbreaks)
  • Sudan ebolavirus
  • Reston ebolavirus (not known to cause disease in humans)
  • Taï Forest ebolavirus
  • Bundibugyo ebolavirus

Marburg: Marburg virus

Risk Factors:

  • Communities Around Game Parks: Proximity to wildlife increases the risk of exposure.
  • Endemic Areas: Regions with a history of EVD outbreaks.
  • Cultural Practices: Burial rituals involving close contact with the deceased can facilitate transmission.
  • Poor Infection Control: Inadequate sanitation and hygiene practices in healthcare settings can increase the spread.
  • History of Exposure: Contact with infected individuals within 2-21 days prior to symptom onset (e.g., sexual partners, breastfeeding mothers).
  • Contact with Infected Animals: Handling infected animals (like monkeys, bats, and infected game meat).

Clinical Features:

Early Signs (Non-Specific):

  • Sudden Fever: A rapid onset of high fever (often exceeding 101.5 °F / 38.6 °C).
  • Weakness: General feeling of weakness and exhaustion.
  • Headache: Intense headache.
  • Muscle Pain: Pain in muscles and joints.
  • Loss of Appetite: Decreased appetite or inability to eat.
  • Conjunctivitis: Inflammation of the conjunctiva (white part of the eye).

Late Signs:

  • Diarrhea: Profuse diarrhea, sometimes with blood.
  • Vomiting: Severe vomiting.
  • Mucosal and Gastrointestinal Bleeding: Bleeding from the nose, gums, eyes, and rectum.
  • Chest Pain: Pain in the chest area.
  • Respiratory Distress: Difficulty breathing.
  • Circulatory Shock: Low blood pressure and impaired blood flow.
  • CNS Dysfunction: Confusion, seizures, and coma.
  • Miscarriage in Pregnancy: EVD can cause miscarriage or stillbirth in pregnant women.
  • Elevated AST and ALT: Elevated levels of liver enzymes, indicating liver damage.
  • Kidney Injury: Damage to the kidneys, potentially leading to kidney failure.
  • Electrolyte Abnormalities: Imbalances in electrolytes (minerals like potassium and sodium) in the body.

Other clinical presentations include; 

  • Sudden Onset: Symptoms usually appear abruptly.
  • Severe Headache: Intense headache is a common initial symptom.
  • Myalgia and Fever: Muscle pain (myalgia) and high fever (often exceeding 38.5 °C).
  • Conjunctival Inflammation: Inflammation of the conjunctiva (white part of the eye).
  • Gingival Bleeding: Bleeding from the gums.
  • Sore Throat: Sore throat with associated chest pain.
  • Abdominal Pain: Pain in the abdomen.
  • Nausea, Vomiting, and Diarrhea: These symptoms are prominent features of EVD, with diarrhea often being profuse and watery.
  • Signs of Dehydration: Dehydration can develop due to fluid loss from vomiting and diarrhea.
  • Severe Bleeding: Internal and external bleeding may occur from the gastrointestinal tract, gums, nose, and other orifices. This typically develops between the 5th and 7th days.
  • Morbiliform Rash: A rash similar to measles may appear on the 7th day.
  • Neurological Manifestations: Neurological complications such as psychosis and hemiplegia (weakness or paralysis on one side of the body) can occur.
  • Death: Death often occurs around the 9th day, but can happen between the 2nd and 21st days.

Note: Hemorrhage is not always a prominent feature of EVD. It’s important to remember that EVD symptoms can vary significantly.

Differential Diagnosis:

  • Malaria: A parasitic disease that also causes fever, headache, and muscle aches.
  • Meningitis: Inflammation of the membranes surrounding the brain and spinal cord.
  • Shigellosis: A bacterial infection causing diarrhea, abdominal cramps, and fever.
  • Typhoid Fever: A bacterial infection causing high fever, headache, and constipation.
  • Anthrax: A bacterial infection causing skin lesions, fever, and respiratory problems.
  • Sepsis: A serious bacterial infection causing fever, chills, and rapid heart rate.
  • Viral Hepatitis: Inflammation of the liver caused by viruses like hepatitis A, B, or C.
  • Dengue Fever: A viral infection transmitted by mosquitoes, causing fever, headache, and muscle pain.

Investigations:

Blood Sample for Specific Testing: Blood samples from suspected EVD cases should be collected by trained healthcare professionals wearing proper PPE.

  • Laboratory Testing: The blood sample needs to be sent to a reference laboratory for specific tests to identify the Ebola virus.
  • Real-Time PCR: This is the preferred method for detecting Ebola virus.
  • Antigen and Antibody Detection: ELISA (enzyme-linked immunosorbent assay) and other antibody tests can identify Ebola virus antigens and antibodies.

Postmortem: If an individual dies from EVD, postmortem examination is critical for confirmation and to prevent further spread.

Notification: Immediately notify the district surveillance focal person if you suspect a case of EVD.

Management

Management Aims:

  • Fluid Replacement: Maintain adequate hydration to compensate for fluid loss.
  • Prevention of Spread: Isolate the patient and implement strict infection control measures.
  • Conservation of Energy: Provide rest and supportive care to conserve energy.
  • Symptom Relief: Administer medications to manage symptoms like fever, pain, and vomiting.

Specific Management:

1. Admission: Admit the patient to an isolated room in a medical ward, providing complete bed rest.

  • Bed Preparation: Use a freshly prepared bed, with a comfortable position for the patient (supine or semi-recumbent depending on their condition).

2. Protection:

  • Handwashing: Strict handwashing before and after attending to the patient.
  • Isolation: Isolate the patient in a designated room, and implement barrier nursing techniques. Healthcare workers and patient attendants should wear gowns, gloves, goggles, and gumboots to prevent contact with bodily fluids.
  • Identification Tag: Place an “INFECTIOUS” tag on the door to alert others about the infectious nature of the room.

3. Fluid Replacement: Administer intravenous fluids (N/S, RL, and Dextrose 5%) according to the doctor’s prescription.

4. Hygiene:

  • Patient Hygiene: Maintain cleanliness of the patient’s skin, secretions, and stool. Disinfect with bleach solutions before disposal.
  • Bed Pans: Scrub bed pans thoroughly with strong detergent, rinse, and dry.
  • Patient’s Orifices: Wash and dry the patient’s orifices. Apply perineal pads if needed for profuse diarrhea.
  • Linens: Disinfect linens in a bleach solution for at least 6 hours. Label and transport them in “infected linen” bags to be sluiced, boiled, dried, and ironed.
  • Room Disinfection: Mop the room, scrub the floors and walls, disinfect lockers, and wash and boil patient utensils for at least 10 minutes.
  • Refuse Disposal: Place food and hospital refuse in polythene bags and incinerate.

5. Diet: Provide a fluid diet in the acute stage, primarily through IV fluids and oral fluids as much as possible.

6. Terminal Disinfection: Thoroughly disinfect the room and all contaminated materials after the patient is discharged.

7. Notification: Report the case to health authorities to inform the public health system about the outbreak.

Health Education:

  • Patient Attendants: Educate patient attendants about the infection, its mode of transmission, and prevention measures.
  • General Public: Inform the general public about the disease, its signs and symptoms, and preventative measures.
  • Patient Care: Ensure the patient feels supported and understood, preventing isolation and stigma.

Prevention:

  • Avoid Contact: Minimize contact with the patient’s blood and secretions.
  • Personal Protective Equipment: Wear proper PPE (gowns, gloves, masks, eye protection) when providing care.
  • Safe Burial Practices: Use safe burial practices to prevent transmission during funerals.
  • Vaccination: The Ebola vaccine is available and should be considered for high-risk individuals.
  • Isolation: Isolate infected individuals in designated Ebola treatment centers.
  • Contact Tracing: Identify and monitor individuals who have come into contact with infected persons.

Prevention Complications:

  • Shock: Monitor for signs of shock (low blood pressure, rapid heart rate, weakness, and cool, clammy skin).
  • Organ Failure: Monitor for signs of organ failure (e.g., jaundice for liver failure, decreased urine output for kidney failure).
  • Disseminated Intravascular Coagulation (DIC): Be aware of the signs of DIC (bleeding from multiple sites, bruising, and difficulty controlling bleeding).
  • Meningitis: Monitor for signs of meningitis (stiff neck, headache, fever).
  • Encephalitis: Monitor for signs of encephalitis (confusion, seizures).
  • Secondary Infections: Monitor for signs of secondary infections (fever, cough, difficulty breathing).
  • Psychological Trauma: Provide psychological support to patients and their families to address potential psychological trauma.

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Brucellosis

Brucellosis (Undulant Fever, Malta Fever, Abortus Fever)

Brucellosis is a zoonotic bacterial infection of acute onset, commonly known as undulant fever, Malta fever, or abortus fever. 

It’s primarily an occupational disease among people working with infected livestock or associated fresh animal products. This includes butchers, farmers, abattoir workers, and vendors of contaminated roasted meat (muchomo).

Incubation Period:

The incubation period for brucellosis is typically 2-4 weeks, but can range from 1 to 8 weeks.

Forms of Transmission:

  • Direct Contact: Contact with infected animals, particularly during handling, slaughtering, or birthing, can lead to transmission.
  • Ingestion: Consuming unpasteurized milk, cheese, or other dairy products from infected animals is a common route of transmission.
  • Inhalation: Inhaling contaminated aerosols, particularly in settings where animal products are processed or handled, can lead to infection.
  • Accidental Exposure: Laboratory workers or those handling animal products in agricultural settings may be at risk of accidental exposure.

Routes of Transmission:

  • Occupational Exposure: Farmers, veterinarians, slaughterhouse workers, and laboratory workers are at increased risk of exposure due to their close contact with infected animals.
  • Consumption of Contaminated Products: Consuming unpasteurized milk, cheese, or other dairy products from infected animals is a common route of transmission.
  • Accidental Exposure: Accidental exposure to contaminated materials or aerosols, particularly in laboratory settings, can lead to infection.
 

Causes/Aetiology:

Brucella Species: The most common species of Brucella that infect humans are:

  • Brucella abortus (cattle)
  • Brucella melitensis (goats and sheep)
  • Brucella suis (pigs)
  • Brucella canis (dogs)

Clinical Features:

Brucellosis is known for its diverse range of symptoms, which can appear anywhere from a few days to several weeks after infection. Common features include:

  1. Fever: High-grade fever, often accompanied by chills and sweats.
  2. Fatigue and Weakness: Profound fatigue, lethargy, and muscle aches.
  3. Headache and Stiff Neck: Persistent headache, often accompanied by neck stiffness.
  4. Arthritis and Muscle Pain: Pain and inflammation in joints, particularly in the spine and large joints.
  5. Sweating: Excessive sweating, particularly at night.
  6. Weight Loss: Unintentional weight loss due to poor appetite and decreased food intake.
  7. Depression: Emotional disturbances, including depression, anxiety, and irritability.
  8. Splenomegaly and Hepatomegaly: Enlargement of the spleen and liver.
  9. Orchitis: Inflammation of the testicles in men.
  10. Endocarditis: Infection of the heart valves.
  11. Meningitis: Inflammation of the meninges (membranes surrounding the brain and spinal cord).

Differential Diagnosis:

  • Typhoid fever: Similar symptoms, including high fever, headache, and muscle aches.
  • Malaria: Fever episodes that coincide with mosquito bites.
  • Tuberculosis: Chronic cough, night sweats, and weight loss.
  • Trypanosomiasis (sleeping sickness): Fever, headache, and fatigue, often accompanied by neurological symptoms.
  • Other causes of prolonged fever: Other infections, autoimmune disorders, and certain cancers can also cause prolonged fever.

Definitive Diagnosis and Investigations:

  • Blood Culture: A positive blood culture for Brucella is considered the definitive diagnosis.
  • Serological Tests: Serological tests, such as the agglutination test and the enzyme-linked immunosorbent assay (ELISA), can detect antibodies against Brucella bacteria.
  • Other Tests: Additional tests, such as bone marrow culture, urine culture, or biopsy, may be necessary depending on the clinical presentation.
  • Blood: Complement fixation test or agglutination test (where possible).
  • Isolation of the infectious agent from blood, bone marrow, or other tissues by culture.

Management:

Treatment:

Adults and children > 8 years:

  • Doxycycline 100 mg every 12 hours for 6 weeks
  • Plus gentamicin 5-7 mg/kg IV daily for 2 weeks
  • Or ciprofloxacin 500 mg twice daily for 2 weeks

Children < 8 years:

  • Cotrimoxazole 24 mg/kg every 12 hours for 6 weeks
  • Plus gentamicin 5-7 mg/kg IV in single or divided doses for 2 weeks

Caution:

  • Treatment duration must be adhered to at all times.
  • Ciprofloxacin is contraindicated in children <12 years.
  • Doxycycline and gentamicin are contraindicated in pregnancy.

Prevention:

  • Public health education:
  1. Drinking only pasteurized or boiled milk.
  2. Careful handling of pigs, goats, dogs, and cattle, especially if a person has wounds or cuts.
  • Veterinary services: Provide veterinary services for domestic animals to prevent the spread of infection.
  • Safe handling practices: Use proper hygiene practices when handling animals and wear protective clothing.
  • Occupational safety: Implement safety protocols and use PPE in occupational settings where exposure to infected animals or their products is likely.
  • Food safety: Consume only pasteurized milk, cheese, and other dairy products. Avoid eating raw or undercooked meat from animals suspected of being infected with Brucella.
  • Travel precautions: Advise travelers to countries where brucellosis is endemic to be aware of the risks and take necessary precautions.

Complications:

  • Endocarditis: Infection of the heart valves, which can be life-threatening.
  • Meningitis: Inflammation of the meninges, which can lead to neurological complications.
  • Arthritis: Inflammation of joints, particularly in the spine and large joints.
  • Osteomyelitis: Infection of the bone, which can lead to bone damage and disability.
  • Hepatitis: Inflammation of the liver.
  • Orchitis: Inflammation of the testicles in men.
  • Chronic Fatigue Syndrome: Persistent fatigue and other symptoms, which can significantly impact quality of life.
  • Neurological complications: Neurological complications can occur in severe cases and may include encephalitis, seizures, and coma.

Brucellosis Read More »

HOME VISITING IN COMMUNITY HEALTH

HOME VISITING IN COMMUNITY HEALTH

Home visiting is highly essential to community health services, as a large number of patients are found in their homes.

Home visiting refers to the process of providing nursing care to patients at their residences.

Objectives of Home Visiting:

  • Establish close relationships with the community and families.
  • Assess the living conditions of families and identify how these conditions affect their health.
  • Promote family health by providing health education tailored to the age and developmental stage of each family member.
  • Monitor the skills learned during health education sessions.
  • Demonstrate to families how to administer necessary healthcare to other family members.
  • Refer families to appropriate specialized services when needed.

Factors Influencing the Growth of Home Visiting Services:

  • Increasing elderly population facing chronic illnesses.
  • Increased prevalence of HIV/AIDS.
  • Advanced technology enabling home-based healthcare services.
  • Rising cost of healthcare.
  • Growing demand for consumer satisfaction.

Principles of Home Visiting:

When conducting home visits, community nurses should adhere to these essential principles:

  • Purposeful and beneficial: Home visits should be planned with a clear objective and be beneficial to the patients.
  • Needs-driven: The purpose of each visit should align with the specific needs of the patient.
  • Beyond surveys and statistics: Home visits shouldn’t solely rely on surveys or data collection but should incorporate health education and practical support.
  • Regular and flexible: Visits should be scheduled regularly but adjusted according to the patient’s needs.
  • Educational: Home visits provide excellent opportunities for health education.
  • Convenient and acceptable: Visits should be convenient for the patient and respect their preferences.
  • Demonstrative: Home visits should provide nurses with the opportunity to demonstrate hygienic principles.

Effective Home Visiting Practices:

  • Family-centered approach: The nurse should actively involve each family member in the care process.
  • Positive relationships: Nurses and families should work collaboratively to build strong, trusting relationships that support goal achievement.
  • Respect for patient autonomy: Nurses must respect the patient’s right to accept or refuse care and participate in setting and reaching goals.
  • Record-keeping: Home visits should be documented in the patient’s medical records to ensure continuity of care.

Advantages of Home Visits:

  • Provides an ideal setting for implementing the nursing process.
  • Offers an opportunity to assess the home and family situation.
  • Allows nurses to provide services in the patient’s familiar environment.
  • Facilitates strong relationships between nurses and families.
  • Addresses family concerns and clarifies doubts.
  • Enables nurses to observe family practices and the progress of care.
  • Supports modification of care plans based on observations.
  • Offers a viable option for patients unable or unwilling to travel.
  • Creates a comfortable atmosphere for discussing concerns and needs.

Components of Home Visiting:

1. Initiation Phase: The community health nurse clarifies the source of referral for the visit, its purpose, and shares this information with the family.

2. Pre-visit Activities: Prior to the visit, nurses gather information about the family, including location, distance, address, and the reason for the visit. This may involve reviewing family folders, consulting other nurses or family members, or contacting health agencies. Information gathered may include age, sex, family structure, culture, values, problems, current care, etc. This information helps the nurse plan appropriately for the visit and address the patient’s needs effectively.

3. Activities During Home Visits: Community health nurses use their skills to build rapport and trust with the family, which is crucial for a positive relationship. The nurse-patient relationship is vital for providing healthcare services in the community. The nurse introduces herself, establishes her professional identity, and builds the nurse-patient relationship. This relationship should be characterized by:

  • One person possessing knowledge and skills that can benefit another.
  • The needs of the person receiving assistance taking priority.
  • The relationship being self-limiting based on the goals to be achieved.
  • The person receiving assistance needing and utilizing the support.
  • The assistance being provided competently.
    During visits, the nurse assesses the family’s needs and plans nursing care accordingly.

4. Termination Phase: The termination of home visits occurs when:

  • The nurse-patient goals are achieved, health is restored, and the patient can function without nursing assistance.
  • The patient changes residence or moves to another care setting.
  • The nurse transfers the patient’s care to another nurse or caregiver.

5. Post-visit Activities: These include recording and reporting. The nurse documents important events within the family, reports necessary information to higher authorities, discusses family problems with colleagues and other health team members, and plans accurately to meet the family’s needs.

Areas Associated with Home Visiting:

  • General cleanliness
  • Solid waste disposal
  • Latrine/Toilet facilities
  • Personal hygiene
  • Infant vaccination (under 1 year)
  • Women’s vaccination
  • Antenatal care
  • Presence of insects or rodents in the home
  • Feeding practices for children over 2 years old
  • Family planning
  • Presence of sick individuals in the house and actions taken.

Limitations of Home Visiting:

  • Time-consuming
  • Limited equipment can be transported to homes.
  • Appointments may not be kept.
  • Uncooperative or violent family members.
  • Some homes may be geographically inaccessible.
  • Language barriers.

Problems with Home Visits:

  • Time and energy consumption: Community health nurses may spend a considerable amount of time traveling to and from homes, which can impact the time available for providing care.
  • Non-acceptance: Families may not accept the nurse due to cultural differences, personal characteristics, or socioeconomic status.
  • Language barriers: Communication difficulties can arise if the nurse is unfamiliar with the local language.
  • Role confusion: Some individuals or families may not fully understand the role of a nurse in home visiting, leading to confusion about expectations.

HOME VISITING IN COMMUNITY HEALTH Read More »

Vaccines and Immunoglobulins

Vaccines and Immunoglobulins

Vaccines are special preparations of antigenic materials that can be used to stimulate the development of antibodies and thus confer active immunity against a specific disease or a number of diseases. 

Vaccines may be single component or mixed combined vaccines.

Types of Vaccines

Live Attenuated Vaccines: These vaccines contain live microbes that have been weakened (attenuated). Live attenuated vaccines usually confer immunity with a single dose which is of long duration. They may be dangerous in recipients who are immunocompromised because these patients are unable to mount an effective immune response.

Examples:

  • Mumps vaccines
  • Measles vaccines
  • BCG vaccines
  • Rubella vaccines
  • Chickenpox vaccines

Killed or Inactivated Vaccines: This type of vaccine contains whole inactivated microbes. Inactivated vaccines may require a series of injections in order to produce an adequate body response and in most cases booster doses are required.

Examples:

  • Polio vaccines

Toxoids: Toxoid vaccines use bacterial toxins that have been rendered harmless. Administration of the toxoid causes the recipient’s immune system to manufacture antitoxins directed against the bacterial toxins.

Examples:

  • Tetanus toxoid

Immunity

Immunity is the body’s ability to resist infections afforded by the presence of circulating antibodies and white blood cells.

Types of Immunity

  • Active Immunity: Active immunity is induced by the administration of microorganisms or their products which act as antigens to induce the body to produce antibodies.
  • Passive Immunity: Passive immunity is obtained by injecting preparations made from the plasma of immune individuals with adequate levels of antibodies to the disease for which protection is sought. Treatment should be given as soon as possible after exposure for effective results. This type of immunity lasts for only a few weeks.
Poliomyelitis Vaccine

Available Preparations:

  • Oral suspension of live attenuated poliomyelitis virus

Indications:

  • Active immunization against poliomyelitis

Contraindications:

  • Hypersensitivity to any of the ingredients
  • Patients with diarrhea or vomiting
  • Immunocompromised patients
  • Pregnancy

Dosage:

  • 2 drops at birth
  • 2 drops at 6 weeks
  • 2 drops at 10 weeks
  • 2 drops at 14 weeks

Side Effects:

  • Rarely seen

Drug Interactions:

  • Concomitant administration with immunosuppressant drugs

Key Issues to Note:

  • Live polio vaccine loses potency once the container has been opened; therefore, discard any unused preparation
  • Breastfeeding does not interfere with immunization even though polio antibodies may be excreted in breast milk
  • If the vaccine is vomited, repeat the dose immediately
  • A child who has previously had polio should nevertheless be immunized to offer complete protection
Measles Vaccine

Available Preparations:

  • Injection powder for solution (live attenuated measles virus)

Available Brands: Sii® measles vaccine live

Indications:

  • Active immunization against measles

Contraindications:

  • Hypersensitivity to any antibiotic present in the vaccine
  • Hypersensitivity to eggs

Dosage:

  • 0.5 ml SC at 9 months (left upper arm)

Side Effects:

  • Fever
  • Malaise
  • Thrombocytopenia
  • Headache
  • Rashes

Key Issues to Note:

  • Vaccination is recommended in all children at the age of 9 months
  • Maternal antibodies may interfere with an effective immune response to the vaccine if given in the first 6 months of life
  • The vaccine may be given at 6 months in case there is an outbreak in the community
  • Vaccination should not be given to patients with untreated active tuberculosis
Measles, Mumps, and Rubella Vaccine (MMR Vaccine)

Available Preparations:

  • Injection of live attenuated measles, mumps, and rubella virus

Available Brands: Sii® measles, mumps, and rubella vaccine, Trimovax®, Priorix®

Indications:

  • Active immunization against measles, mumps, and rubella

Contraindications:

  • Pregnancy
  • Hypersensitivity to any antibacterial such as neomycin or kanamycin used in the manufacturing process
  • Immunosuppressed patients

Dosage:

  • By deep SC or by intramuscular injection 0.5 ml (12-15 months)

Side Effects:

  • Fever
  • Parotid swelling
  • Malaise
  • Rash

Drug Interactions:

  • Concomitant administration with immunosuppressant drugs
BCG Vaccine

Available Preparations:

  • Powder for injection of live bacteria of a strain derived from the bacillus of Calmette and Guerin

Indications:

  • Active immunization against tuberculosis

Contraindications:

  • Generalized edema
  • Immunosuppressed patients
  • Antimycobacterial treatment
  • Previous TB infections

  • Generalized skin diseases

  • Tuberculin reaction > 5 mm

Dosage:

  • 0.05 ml intradermally in the right upper arm (infants less than 12 months)
  • 0.1 ml intradermally on the right upper arm (adults and children greater than 12 months)

Side Effects:

  • Keloid formation
  • Lymphadenitis
  • Localized necrotic ulceration
  • Anaphylaxis
  • Disseminated BCG infection in immunosuppressed patients

Drug Interactions:

  • Concomitant administration with immunosuppressant drugs
DPT Vaccine

Available Preparations:

  • Powder for injection

Available Brands: TriPacel®, Infanrix®

Indications:

  • Active immunization against diphtheria, tetanus, and pertussis

Dosage:

  • Infant: 0.5 ml by intramuscular or deep SC injection at 6, 10, and 14 weeks

Side Effects:

  • Irritability
  • Restlessness
  • Limb swelling
  • Malaise
  • Peripheral neuropathy
  • Myalgia
  • Urticaria
  • Headache
  • Fever
  • Loss of appetite
Tetanus Toxoid Vaccine

Available Preparations:

  • Injection

Available Brands: Sii® tetanus toxoid vaccine, Tetavax®

Indications:

  • Active immunization against tetanus and neonatal tetanus

Dosage:

  • Women 15-45 years of age including pregnant women: 0.5 ml deep SC or intramuscular injection at first contact or as early as possible during pregnancy (TT1)
  • TT2 (0.5 ml) at least 4 weeks after TT1 or during subsequent pregnancy
  • TT3 (0.5 ml) at least 6 months after TT2 or during the subsequent pregnancy
  • TT4 (0.5 ml) at least 1 year after TT3 or during subsequent pregnancy
  • TT5 (0.5 ml) at least 1 year after TT4 or during subsequent pregnancy

Note: To achieve lifelong protection against tetanus, 5 doses of TT are required.

Side Effects:

  • Peripheral neuropathy
Anti-Tetanus Immunoglobulin

Available Preparations:

  • Injection 1500 IU

Available Brands: Tetanea®

Indications:

  • Passive immunization against tetanus as part of the management of tetanus-prone wounds

Dosage:

  • Adult and Children: 1 ml by IM injection. Give additional dose if wound is older than 12 hours or heavily contaminated

Side Effects:

  • Local reactions
  • Fever
  • Pain and tenderness at the site of injection
  • Headache
Yellow Fever Vaccine

Available Preparations:

  • Injection powder + solvent of live attenuated virus

Available Brands: Stamaril®

Indications:

  • Active immunization against yellow fever

Contraindications:

  • Immunosuppressed patients
  • Known hypersensitivity to any of the ingredients
  • Infants under 4 months of age
  • Hypersensitivity to eggs

Dosage:

  1. Infants at 9 months: 0.5 ml by SC injection
  2. Immunization of travelers and others at risk:
  • Adult and Children over 9 months: 0.5 ml
  • Infants 4-9 months: 0.5 ml only if the risk of yellow fever is unavoidable

Side Effects:

  • Headache
  • Fever
  • Weakness
  • Diarrhea
  • Myalgia
  • Influenza-like symptoms
  • Nausea

Drug Interactions:

  • Concomitant administration with immunosuppressant drugs
  • Cholera vaccine should not be given together with yellow fever vaccine
Typhoid Vaccine

Available Preparations:

  • Injection VI capsular polysaccharide typhoid 25 mcg/0.5 ml

Available Brands: Typhim Vi®, Typherix®

Indications:

  • Active immunization against typhoid

Contraindications:

  • Immunosuppressed patients
  • Febrile illness
  • Known hypersensitivity to any of the ingredients

Dosage:

  • Adult and children over 2 years: By deep SC (subcutaneous) or intramuscular 0.5 ml with booster doses every 3 years for those at continued risk

Side Effects:

  • Headache
  • Allergic reaction
  • Myalgia
  • Fever
  • Nausea
  • Malaise
  • Swelling and pain

Key Issues to Note:

  • Typhoid fever prevention becomes effective after 2-3 weeks after injection
  • Typhoid is rare in children under 2 years; therefore, to immunize in this age group should be based on the risk of exposure
  • The vaccine offers protection for a minimum duration of 3 years
Pneumococcal Vaccine

Available Preparations:

  • Injection in form of 23-valent polysaccharide vaccine 25 mcg/0.5 ml

Available Brands: Pneumo 23®

Indications:

Immunization against pneumococcal infections in:

  • Sickle cell disease in children over 2 years of age
  • Immunocompromised patients over 5 years at increased risk of pneumococcal infection

Contraindications:

  • Severe allergic reaction to any of the ingredients

Dosage:

  • Adult and children over 2 years: 0.5 ml deep SC or IM as a single dose

Side Effects:

  • Fever
  • Myalgia
  • Pain and erythema at injection site

Key Issues to Note:

  • Revaccination is recommended every 5-10 years in high-risk patients
Meningococcal Vaccine

Available Preparations:

Injection

  • Bivalent vaccine from group A and C
  • Tetravalent vaccine from groups A, C, Y, and W135

Available Brands: Meningo A + C®, Mencevax ACWY®

Indications:

  • Active immunization against Neisseria meningitidis infections such as meningitis and septicemia

Contraindications:

  • Allergy to diphtheria toxoid
  • Febrile conditions

Dosage:

  • Bivalent: 0.5 ml deep SC or IM injection as a single dose
  • Tetravalent: 0.5 ml deep SC injection as a single dose

Side Effects:

  • Allergic reaction
  • Anaphylaxis
  • Erythema

Key Issues to Note:

  • Do not use in children under 2 years except in epidemic situations
Cholera Vaccine

Available Preparations:

  • Oral vaccine containing live attenuated or inactivated

Available Brands: Dukoral®

Indications:

  • Immunization for travelers over 2 years of age at high risk of cholera infections

Contraindications:

  • History of hypersensitivity to any of the ingredients
  • Acute GIT or febrile

Dosage:

  • Children 2-6 years: 3 doses given at intervals of at least 1 week. Give a booster after 6 months if still at risk
  • Adult and Children over 6 years of age: 2 doses given at 1-week intervals. Give a booster after 2 years if still at risk

Side Effects:

  • Abdominal discomfort
  • Headache
  • Diarrhea
  • Fever

Key Issues to Note:

  • Avoid food and drinks 1 hour before and after taking the vaccine
Rabies Vaccine

Available Preparations:

  • Injection 2.5 IU/dose

Available Brands: Sii rabivax®, Lyssavac berna®, Verorab®

Indications:

  • Active immunization against rabies
  • Post-exposure treatment to prevent rabies in patients who have been bitten by rabid animals
  • Pre-exposure prophylaxis in persons at high risk of being bitten by rabid animals

Contraindications:

  • Known hypersensitivity to any of the ingredients

Dosage:

  • Pre-exposure prophylaxis: 1 ml by deep subcutaneous or intramuscular injection on days 0, 7, and 28
  • Post-exposure treatment: 1 ml by deep subcutaneous or intramuscular injection on days 0, 3, 7, 14, and 30

Side Effects:

  • Pain at injection site
  • Fever
  • Erythema at injection site
  • Malaise
  • Nausea
  • Myalgia
  • Headache
  • Hypersensitivity reaction
Hepatitis B Vaccine

Available Preparations:

  • Injection containing inactivated hepatitis B surface antigen

Available Brands: Euvax B adult®, Euvax B paed®, Engerix B®

Indications:

  • Active immunization against hepatitis B infection

Contraindications:

  • History of hypersensitivity

Dosage:

  • Adult and Children over 15 years: 1 ml with an interval of 1 month between the 1st and 2nd dose and 5 months between the 2nd and 3rd doses. Total of 3 doses
  • Children below 15 years: 0.5 ml with 1 month between the 1st and 2nd dose, and 5 months between the 2nd and 3rd dose
  • Infants: 0.5 ml intramuscular injection at 6 weeks, 10 weeks, and 14 weeks of age

Side Effects:

  • Abdominal pain
  • GIT disturbance
  • Sleep disturbance
  • Lymphadenopathy
  • Muscle and joint pains
  • Dizziness
  • Peripheral neuropathy

  • Myalgia

Key Issues to Note:

  • Immunocompromised patients may need further doses

Anti-D (Rho) Immunoglobulin

A Rhesus-negative mother may develop antibodies against Rho antigen red cells when she carries a Rhesus-positive fetus and fetal red cells enter her circulation during childbirth, abortion, or miscarriage. Rho immunoglobulin is used to prevent non-sensitized mothers from producing antibodies which may cause hemolytic disease of the newborn.

Available Preparations:

  • Injection

Indications:

  • Prevention of Rhesus D sensitization in females who are Rhesus D negative

Contraindications:

  • Rhesus-positive individuals
  • Isolated immunoglobulin A deficiency

Dosage:

  • Following birth of Rhesus-positive infant: 500 units deep IM immediately or within 72 hours
  • Following stillbirth: 250 units per episode immediately or within 72 hours
  • Antenatal prophylaxis: 500 units given at 28 and 34 weeks of pregnancy. A further dose is still needed immediately or within 72 hours of delivery

Side Effects:

  • Local tenderness and stiffness
  • Fever
  • Nausea
  • Vomiting
  • Back pain
  • Abdominal pain
  • Myalgia
  • Malaise
  • Sweating
  • Skin rash

Vaccines and Immunoglobulins Read More »

Drugs Used in Anaesthesia

Drugs Used in Anaesthesia

Anaesthesia is defined as the absence of feelings, sensation, or pain. Anaesthetics are drugs that reduce or abolish sensation, affecting either the whole body (general anaesthetics) or a particular area or region (local anaesthetics).

Local Anaesthetics

Local anaesthetics provide brief periods of anaesthesia in a small localized area of the skin and adjacent tissues. They may be administered in two ways: topically for surface anaesthesia and by injection for infiltration anaesthesia.

Topical anaesthetics are usually applied to the skin or the mucous membrane to relieve itching, insect bites, hemorrhoids, pruritus, and minor surgical procedures.

Infiltration anaesthesia may be achieved by injecting a local anaesthetic into the immediate area of surgery. It is commonly used during dental extraction and biopsies.

Examples:

  • Lidocaine (lignocaine)
  • Bupivacaine
  • Mepivacaine

Note: Lignocaine is sometimes combined with epinephrine (adrenaline), a powerful vasoconstrictor, that decreases blood flow to the tissue where it is injected. Adrenaline controls bleeding and also prolongs the anaesthetic action of lignocaine.

General Anaesthetics

General anaesthetic drugs are normally given IV or by inhalation to produce rapid, reversible loss of consciousness and insensibility to surgical stimuli.

Examples: 

Inhaled Anaesthetics:

  • Halothane
  • Nitrous oxide
  • Ether

Intravenous Anaesthetics:

  • Ketamine
  • Midazolam
  • Propofol

Ketamine

Available Preparations:

  • Injection: 50 mg/ml

Available Brands: Ketajex®, Ketalar®

Pharmacokinetics: Ketamine is rapidly and well absorbed after IM injection, rapidly enters the CNS, metabolized by the liver, and excreted in urine.

Indications:

  • Induction and maintenance of anaesthesia
  • Pain relief
  • Diagnostic maneuvers and procedures not involving intense pain

Contraindications:

  • Thyrotoxicosis
  • Hypertension (including pre-eclampsia)
  • History of cerebrovascular accident
  • Raised intracranial pressure
  • Psychiatric disorders, particularly hallucinations
  • Severe cardiac disease
  • Recent myocardial infarction
  • Stroke
  • Known hypersensitivity to ketamine
  • Cerebral trauma
  • Eye injury

Dosage:

Induction:

  • Intravenous Injection: 1-4.5 mg/kg (2 mg/kg usually produces anaesthesia lasting 5-10 minutes)
  • Intramuscular Injection: 6.5-13 mg/kg (duration of anaesthesia up to 25 minutes)
  • IV Infusion: 0.5-2 mg/kg initially, then infuse at 10-45 mcg/kg/minute, adjust according to response

Maintenance:

  • Intravenously: Increments of half or full dose repeated as required
  • Analgesic for painful procedures: IV 1-1.5 mg/kg slowly over 2-5 minutes. Give half dose every 10 minutes if required for prolonged procedures

Administration Instructions:

  • Dilute dose with an equal volume of water for injection, sodium chloride 0.9%, or glucose 5% before IV injection
  • Give IV slowly; rapid administration may result in respiratory depression and enhanced hypertensive response

Side Effects:

  • Raised blood pressure and pulse rate
  • Increased muscle tone
  • Lacrimation
  • Hypersalivation
  • Raised intracranial pressure
  • Redness of the skin
  • Postoperative nausea and vomiting
  • Pain on injection
  • Irrational behavior during recovery

Drug Interactions:

  • Inhalation anaesthetics such as halothane may prolong the effect of ketamine and delay recovery
  • Prolonged recovery occurs when barbiturates or opioids are given concurrently with ketamine
  • Ketamine should not be used with ergometrine
  • Concomitant use with thyroid hormones may cause hypertension and tachycardia

Key Issues to Note:

  • Warn the patient to avoid tasks requiring motor coordination and/or mental alertness for 24 hours after anaesthesia
  • Keep verbal, tactile, and visual stimulation to a minimum during induction and recovery

Lidocaine

Available Preparations:

  • Solution: 1%, 2%
  • Topical Gel: 2-4%
  • Combinations: Xylocaine® (Lidocaine + epinephrine)

Note: Epinephrine is often added to delay absorption and thus reduce anaesthetic systemic toxicity and keep it in contact with nerve fibers, prolonging the duration of action.

Pharmacokinetics: Lidocaine is effectively absorbed from the mucous membranes, widely distributed throughout the body, metabolized in the liver, and excreted in urine.

Indications:

  • Infiltration anaesthesia
  • Surface anaesthesia of mucous membrane
  • Dental anaesthesia
  • Ventricular arrhythmias
  • Relief of pain in hemorrhoids

Contraindications:

  • Adjacent skin infection
  • Hypersensitivity
  • Heart block
  • Hypovolemia
  • Severe anemia
  • Myasthenia gravis
  • Spinal anaesthesia in dehydrated patients

Dosage:

Dental Anaesthesia: Using 2% solution with epinephrine

  • Adult: 20-100 mg (1-5 ml)

Local Infiltration and Peripheral Nerve Block: Using 1% solution with epinephrine

  • Adult: Up to 400 mg (up to 40 ml)

Note: Use lower doses for elderly, epileptic, or acutely ill patients. Do not use solution containing preservatives for spinal, epidural, intravenous, or regional anaesthesia.

Side Effects:

  • Dizziness
  • Lightheadedness
  • Tremors
  • Numbness
  • Restlessness
  • Convulsions
  • Unconsciousness
  • Headache
  • Blurred vision
  • Hypotension
  • Cardiac arrest
  • Backache
  • Sense of heat
  • Hypersensitivity reaction
  • Urinary retention

Drug Interactions:

  • Anti-convulsants may increase the cardiac depressant effect of lidocaine
  • Cimetidine and beta-blockers may increase plasma concentration of lidocaine, leading to increased risk of toxicity
  • Use of opioid analgesics peri-operatively may have additive respiratory and cardiac depressant effects

Key Issues to Note:

  • Doses should be reduced in acute and chronic hepatic diseases
  • If solutions discolor or precipitate, they should be discarded

Drugs Used in Anaesthesia Read More »

Drugs Used in the Treatment of Cancer

Drugs Used in the Treatment of Cancer

Cancer is a disease characterized by a shift in the control mechanisms that govern cell survival, proliferation, and differentiation. 

Uncontrolled multiplication of cells leads to the formation of tumors that may be benign or malignant. Benign tumors do not spread to other tissues, while malignant tumors do.

Types of Cancer

  • Carcinoma: Affects the skin and cells in the tissue lining internal organs.
  • Sarcoma: Affects muscles, bones, and fibrous tissues.
  • Leukemia: Affects white blood cells.
  • Lymphoma: Affects the lymph glands.

Drugs used in the treatment of cancer either kill cancer cells or modify their growth.

Table 1: Classification of Anticancer Drugs

Class

Examples

Antimetabolites

Methotrexate, 5-Fluorouracil, Cytarabine, 6-Mercaptopurine

Antitumor Antibiotics

Bleomycin, Dactinomycin

Alkylating Agents

Cyclophosphamide, Busulfan, Chlorambucil, Carmustine, Dacarbazine, Melphalan

Anthracyclines

Daunorubicin, Doxorubicin, Idarubicin

Vinca Alkaloids

Vincristine, Vinblastine

Platinum Analogs

Cisplatin

Hormonal Agents

Tamoxifen, Estrogen

Others

Hydroxyurea, Procarbazine

Bleomycin

Available Preparations:

  • Powder for Injection: 15 units/vial

Available Brands: Blenoxane®

Pharmacokinetics: IM administration results in lower serum levels than those occurring after equivalent IV doses. It distributes widely into total body water, mainly in the skin, lungs, kidneys, peritoneum, and lymphatic tissue. It undergoes extensive tissue inactivation in the liver and kidney; bleomycin and its metabolites are excreted primarily in urine.

Indications:

  • Squamous cell carcinoma (head, neck, penis, cervix)
  • Testicular carcinoma
  • Non-Hodgkin’s lymphoma
  • Lymphosarcoma

Contraindications:

  • Pregnancy
  • Breastfeeding
  • Previous allergic reaction

Dosage:

  • A test dose of 1-2 units given 2-4 hours prior to therapy is recommended.
  • 0.25-0.5 unit/kg body weight or 10-20 units/m² body surface area given IV, IM, or SC once or twice weekly.

Side Effects:

  • Skin rash
  • Striae
  • Redness of the skin
  • Fever
  • Acute anaphylactoid reaction
  • Anorexia
  • Urticaria
  • Pruritus
  • Hyperpigmentation
  • Stomatitis
  • Hyperkeratosis
  • Weight loss
  • Progressive pulmonary fibrosis
  • Mucositis
  • Pneumonitis
  • Phlebitis
  • Vomiting

Drug Interactions:

  • Cisplatin may decrease bleomycin clearance and increase the risk of bleomycin toxicity.
  • Concomitant use may decrease serum levels of phenytoin and digoxin.

Key Issues to Note:

  • Increased pigmentation, particularly affecting the flexures and subcutaneous sclerotic plaques, may occur.
  • A test dose should be administered before starting therapy to check for hypersensitivity reactions.
  • Monitor pulmonary function tests during treatment.

Doxorubicin

Available Preparations:

  • Powder for Injection: 10 mg/vial, 50 mg/vial

Available Brands: Doxorubin®

Pharmacokinetics: It distributes widely into body tissues, with the highest concentrations found in the liver, heart, kidneys, skin, and muscles; it does not cross the blood-brain barrier. It is metabolized both in the liver and plasma; excreted largely in feces, with small amounts in urine.

Indications:

  • Acute leukemia
  • Lymphomas
  • Breast carcinoma
  • Thyroid carcinoma
  • Non-Hodgkin’s lymphoma
  • Ovarian carcinoma
  • Bone and soft tissue sarcomas
  • Hodgkin’s disease
  • Kaposi’s sarcoma in patients with AIDS
  • Transitional cell bladder carcinoma

Contraindications:

  • Hepatic dysfunction
  • Cardiomyopathy
  • Pregnancy and lactation
  • Persistent myelosuppression
  • Severe cardiac failure
  • Recent myocardial infarction

Dosage:

  • 60-74 mg/m² or 1.2-2.4 mg/kg once every 3 weeks as a single intravenous injection of a solution in sodium chloride 0.9% or glucose 5% over 3 minutes or more.
  • Children: 35-75 mg/m² as a single intravenous injection, once every 3 weeks.

Side Effects:

  • Bone marrow depression
  • Anorexia
  • Hyperpigmentation of nail beds
  • Diarrhea
  • Irreversible CHF
  • Reversible alopecia
  • Nausea and vomiting
  • Stomatitis
  • Fever and chills
  • Urticaria
  • Conjunctivitis
  • Lacrimation

Drug Interactions:

  • Cholestasis induced by mercaptopurine may be potentiated by the concurrent administration of doxorubicin.
  • Concomitant use of daunorubicin or cyclophosphamide may potentiate the cardiotoxicity of doxorubicin through additive effects on the heart.
  • Serum digoxin, carbamazepine, and phenytoin levels may be decreased if used concomitantly with doxorubicin.
  • Phenobarbitone increases the elimination of doxorubicin.

Key Issues to Note:

  • Notify the patient that the urine may turn red for the first 1-2 days.
  • Doxorubicin may induce hyperuricemia; therefore, monitor the patient’s blood uric acid levels.
  • Encourage the patient to take adequate fluid intake to increase urine output and facilitate excretion of uric acid.
  • Advise the patient to call if fever, bleeding, and sore throat occur.
  • Avoid exposure to sunlight to prevent sunburns.
  • Warn the patient that alopecia will occur. Explain that hair growth should resume 2-5 months after the drug is stopped.
  • Tell the patient not to receive any immunization during therapy and for several weeks after.
  • Advise the patient to avoid exposure to people with infections.

Methotrexate

Available Preparations:

  • Tablets: 2.5 mg
  • Injection: 25 mg/ml

Available Brands: Texol®

Indications:

  • Treatment and palliation of solid tumors
  • Burkitt’s lymphoma
  • Leukemia
  • Psoriasis

Contraindications:

  • Known hypersensitivity to methotrexate
  • Pregnancy and lactation
  • Severe hepatic and renal impairment
  • Bone marrow suppression
  • Anemia
  • Immunodeficiency syndromes
  • Active infection

Dosage:

  • Leukemia: 15-30 mg/m² orally, intramuscularly, or intravenously; once a week.

Side Effects:

  • Nausea and vomiting
  • Stomatitis
  • Diarrhea
  • Anorexia
  • Malaise
  • Headache
  • Skin rash
  • Dermatitis
  • Pruritus
  • Dizziness
  • Blurred vision

Drug Interactions:

  • Concomitant use with probenecid and salicylates increases the therapeutic and toxic effects of methotrexate by inhibiting its renal clearance.
  • Alcohol enhances the hepatotoxicity caused by methotrexate.
  • Phenytoin, co-trimoxazole may give additive antifolate activity and increase the risk of methotrexate toxicity.

Key Issues to Note:

  • Full blood count, urea, and liver function tests should be carried out prior to and during treatment.
  • Folinic acid is required for rescue procedures.
  • Patients with hyperuricemia should maintain adequate fluid intake and alkalinization of urine.

Vincristine

Available Preparations:

  • Solution for Injection: 1 mg/ml, 0.1 mg/ml

Available Brands: Cristol®

Indications:

  • Leukemias
  • Lymphomas
  • Some solid tumors

Contraindications:

  • Demyelinating form of Charcot-Marie-Tooth syndrome
  • Pregnancy
  • Breastfeeding mothers
  • Current radiotherapy to the liver
  • Known hypersensitivity to vincristine

Dosage:

  • Adult: IV 1.4 mg/m² up to a max weekly dose of 2 mg/m².
  • Children: IV 2 mg/m² once a week.
  • Children < 10 kg: 0.05 mg/kg once a week.

Side Effects:

  • Hair loss
  • Stomatitis
  • Constipation
  • Abdominal cramps
  • Diarrhea
  • Skin rash
  • Headache
  • Jaw pain
  • Hoarseness
  • Diplopia
  • Nausea and vomiting
  • Abdominal distention
  • Urinary tract disturbance
  • Peripheral neuropathy

Drug Interactions:

  • Vincristine may decrease digoxin plasma levels and renal excretion.
  • Vincristine may reduce phenytoin plasma levels.

Key Issues to Note:

  • Allopurinol may be given to prevent uric acid nephropathy.
  • Stool softeners should be used for constipation prophylaxis.
  • Vincristine is a tissue irritant; care should be taken to avoid extravasation.

Tamoxifen

Available Preparations:

  • Tablets: 10 mg, 20 mg

Available Brands: Nolvadex®

Pharmacokinetics: Tamoxifen is well absorbed after oral administration, distributed widely into total body water, metabolized extensively in the liver, and excreted primarily in feces.

Indications:

  • Breast cancer
  • Female infertility (induction of ovulation)

Contraindications:

  • Known hypersensitivity to tamoxifen
  • History of deep vein thrombosis or pulmonary embolism in high-risk women
  • Pregnancy

Dosage:

  • Breast cancer: 20 mg daily.
  • Induction of ovulation (infertility): 20 mg daily on days 2, 3, 4, and 5 of the cycle; if necessary, the daily dose may be increased to 40 mg then 80 mg for subsequent courses.

Side Effects:

  • Hot flushes
  • Nausea
  • Vomiting
  • Lightheadedness
  • Bone pain
  • Confusion
  • Vaginal bleeding
  • Vaginal discharge
  • Headache
  • Decreased libido
  • Weakness

Drug Interactions:

  • Estrogen may decrease the effect of tamoxifen.
  • The anticoagulant effect of oral anticoagulants may be increased by tamoxifen.
  • Bromocriptine may elevate serum levels of tamoxifen.

Key Issues to Note:

  • Adverse effects may be controlled by dosage reduction.
  • Use cautiously in pre-existing leukopenia and thrombocytopenia.
  • Advise women not to become pregnant during therapy with tamoxifen.

Drugs Used in the Treatment of Cancer Read More »

Drugs Used in the Treatment of Obstetric and Gynecological Disorders

Drugs for Menstrual Disorders

The main disorders associated with menstruation that may require treatment include:

  • Amenorrhoea
  • Dysmenorrhoea
  • Menorrhagia
  • Premenstrual syndrome
  • Menopause

Amenorrhoea

Amenorrhoea is the absence of menstruation. A break in menstruation of 6 months or more is considered pathological in an adult woman who is not pregnant, lactating, or has reached menopause.

Amenorrhoea may be classified as:

  • Primary Amenorrhoea: Occurs when a female fails to have her first menstrual cycle by age 16 in the presence of normal secondary sexual characteristics.
  • Secondary Amenorrhoea: The absence of menses for 6 months or more in a woman whose normal menstruation has been established.

Management

  • Identification and correction of any underlying disorder

Dysmenorrhoea

Dysmenorrhoea is painful menstruation that prevents normal activity and requires medication.

Dysmenorrhoea may be classified as:

  • Primary Dysmenorrhoea: Usually begins with the first menstrual period and is characterized by cramping lower abdominal pain, nausea, vomiting, headache, and faintness. The cause is thought to be due to excessive prostaglandin production that causes the uterus to contract painfully.
  • Secondary Dysmenorrhoea: Usually affects older women who complain of congested ache with lower abdominal cramps which usually starts a few days before menstruation. It is associated with various disorders such as endometriosis, pelvic inflammatory disease, fibroids, or the presence of an IUD.

Drugs used in the treatment of primary dysmenorrhoea inhibit either ovulation or prostaglandin production.

Examples:

  • NSAIDs such as mefenamic acid, ibuprofen, indomethacin, naproxen, piroxicam, and diclofenac
  • Oral contraceptives
  • Progestogens (norethisterone)
  • Antispasmodics (hyoscine and drotaverin)

Menorrhagia

Menorrhagia is excessive menstrual bleeding. It may be associated with pelvic disorders such as fibroids, use of copper intrauterine devices, complications of pregnancy, malignant tumors, or dysfunctional bleeding. Menorrhagia may lead to iron deficiency anemia as well as impairing the quality of life of the patient.

Drugs used in the treatment of menorrhagia include:

  • Combined oral contraceptives
  • Mefenamic acid
  • Norethisterone
  • Medroxyprogesterone
  • Tranexamic acid

Pre-menstrual Syndrome

Pre-menstrual syndrome is a cyclic recurrence of psychological and physical symptoms that affect women in the days before menstruation. Symptoms include increased irritability, depression, anxiety, bloating, headache, and breast tenderness.

Drugs used in the treatment of pre-menstrual syndrome include:

  • Calcium supplements
  • Pyridoxine (vitamin B6)
  • Bromocriptine
  • Spironolactone
  • Mefenamic acid
  • Fluoxetine
  • Paroxetine
  • Atenolol

Note:

  • Bromocriptine, mefenamic acid, and spironolactone suppress physical symptoms.
  • Fluoxetine, paroxetine, and atenolol mostly suppress psychological symptoms.

Menopause

Menopause is the occurrence of no menstrual periods for one year after the age of 40 or permanent cessation of ovulation after loss of ovarian activity.

Signs and Symptoms:

  • Atrophic vaginitis
  • Dyspareunia
  • Complete cessation of menses
  • Heavier bleeding
  • Osteoporosis
  • Anxiety
  • Depression
  • Insomnia
  • Inability to concentrate
  • Irritability
  • Decreased libido
  • Urinary incontinence
  • Hot flashes
  • Night sweats
  • Headache
  • Tiredness

Treatment involves the use of hormone replacement therapy and vaginal lubricants.

Norethisterone

Available Preparations:

  • Tablets: 5 mg

Available Brands: Regulate-N®, Primolut-N®

Indications:

  • Dysfunctional uterine bleeding
  • Pre-menstrual syndrome
  • Delay of menstruation
  • Endometriosis
  • Dysmenorrhoea
  • Contraception

Contraindications:

  • Pregnancy
  • Severe liver impairment
  • Previous or existing liver tumors
  • Severe arterial disease
  • Undiagnosed vaginal bleeding
  • Porphyria
  • Hypersensitivity to norethisterone

Dosage:

  • Dysfunctional Bleeding:
  1. To stop bleeding: 5 mg 3 times daily for 10 days
  2. To prevent bleeding: 5 mg twice daily from day 19-26 of the cycle
  • Dysmenorrhoea: 5 mg 3 times daily from day 5-24 for 3-4 cycles
  • Endometriosis: 10-15 mg daily for 4-6 months or longer starting on day 5 of cycle (if spotting occurs, increase dose to 20-25 mg daily, reduce once bleeding has stopped)
  • Delay of Menstruation: 5 mg 3 times daily starting 3 days before anticipated onset of menstruation (menstruation occurs 2-3 days after stopping)
  • Pre-menstrual Syndrome: 5 mg 2-3 times daily from day 19-26 for seven cycles

Side Effects:

  • Nausea
  • Dizziness
  • Headache
  • Menstrual disturbance
  • Weight gain
  • Depression
  • Insomnia

Dydrogesterone

Available Preparations:

  • Tablets: 10 mg

Available Brands: Duphaston®

Indications:

  • Endometriosis
  • Dysfunctional uterine bleeding
  • Pre-menstrual syndrome
  • Habitual and threatened abortion
  • Hormone replacement therapy
  • Infertility
  • Dysmenorrhoea
  • Amenorrhoea
  • Irregular cycles

Contraindications:

  • Severe liver impairment
  • Previous or existing liver tumors
  • Severe arterial disease
  • Undiagnosed vaginal bleeding
  • Porphyria
  • Known hypersensitivity to dydrogesterone

Dosage:

  • Endometriosis: 10 mg 2-3 times daily from day 5-25 of cycle or continuously
  • Dysfunctional Bleeding:
  1. To stop bleeding: 10 mg twice daily (together with an estrogen) for 5-7 days
  2. To prevent bleeding: 10 mg twice daily (together with an estrogen) from day 11-25 of cycle
  • Dysmenorrhoea: 10 mg twice daily from day 5-25 of cycle
  • Amenorrhoea: 10 mg twice daily from day 11-25 of cycle with estrogen therapy from day 1-25 of cycle
  • Pre-menstrual Syndrome: 10 mg twice daily from day 12-26 of cycle
  • Irregular Cycles: 10 mg twice daily from day 11-25 of cycle
  • Habitual Abortion: 10 mg twice daily from day 11-25 of cycle until conception, then continuously until week 20 of pregnancy

Side Effects:

  • Nausea
  • Dizziness
  • Headache
  • Menstrual disturbance
  • Weight gain
  • Depression
  • Insomnia

Drugs for Infertility

Infertility refers to the inability of a woman to conceive or of a man to induce conception. The most common cause of infertility is the failure of either ovulation in females or spermatogenesis in males. In females, infertility may also be due to obstruction of the fallopian tubes or diseases of the lining of the uterus (endometrium).

Drugs used in the treatment of infertility include:

  • Clomifene
  • Bromocriptine
  • Tamoxifen

Clomifene

Available Preparations:

  • Tablets: 50 mg

Available Brands: Clomid®, Clominol®

Pharmacokinetics: It is readily absorbed from the GIT, metabolized by the liver, and excreted in feces.

Indications:

  • Anovulatory infertility

Contraindications:

  • Liver disease
  • Ovarian cysts
  • Hormone-dependent tumors
  • Known hypersensitivity to clomifene
  • Pregnancy (exclude before treatment)
  • Undiagnosed abnormal uterine bleeding

Dosage:

  • Adult: 50 mg daily for 5 days, starting within 5 days of the onset of menstruation (preferably on the second day) or at any time if cycles have ceased.
  • If ovulation does not occur, a second course of 100 mg daily for 5 days may be given starting as early as 30 days after the previous one. In general, 3 courses of therapy are adequate to assess whether ovulation is obtainable.

Side Effects:

  • Visual disturbance
  • Hot flushes
  • Abdominal discomfort
  • Abnormal uterine bleeding
  • Headache
  • Intermenstrual spotting
  • Insomnia
  • Endometriosis
  • Ovarian hyperstimulation
  • Dizziness
  • Hair loss
  • Nausea and vomiting
  • Breast tenderness
  • Weight gain
  • Depression
  • Menorrhagia

Key Issues to Note:

  • Advise the patient of the possibility of multiple births. The risk increases with higher doses.
  • Since the drug may cause dizziness or visual disturbances, warn the patient to avoid hazardous tasks until the response to the drug is known.

Drugs Used in the Treatment of Pre-eclampsia and Eclampsia

Pre-eclampsia is a condition that develops late in pregnancy after the 20th week of gestation, characterized by hypertension, proteinuria, and edema of the legs, hands, and face. Severe pre-eclampsia (BP > 160/110 mmHg) may result in morbidity and mortality for the mother or baby. It can lead to poor intrauterine growth and early delivery.

Eclampsia

Eclampsia is the occurrence of seizures or coma in a mother with pre-eclampsia occurring at greater than 20 weeks of gestation or less than 48 hours postpartum. Eclampsia is a threat to both mother and baby and must be treated immediately.

Drugs used in eclampsia include:

  • Magnesium sulphate
  • Hydralazine

Magnesium Sulphate

Available Preparations:

  • Injection: 50%

Indications:

  • Eclampsia (prevention of recurrent seizures)
  • Severe renal failure
  • Myocardial damage
  • Intestinal obstruction

Dosage:

By Intravenous Injection:

  • Start with a loading dose of 4 g by IV infusion in 0.9% sodium chloride over 15 to 20 minutes. Then administer a maintenance dose of 1 g per hour by continuous IV infusion for at least 24 hours until the last seizure.
  • Alternatively, start with a loading dose of 4 g by IV infusion in 0.9% sodium chloride over 15 to 20 minutes. Then administer by IM 10 g (5 g in each buttock) followed by 5 g every 4 hours for at least 24 hours after delivery or the last seizure.
  • Find more details by clicking here.

Side Effects:

  • Nausea and vomiting
  • Flushing of skin
  • Respiratory depression
  • Coma
  • Arrhythmias
  • Thirst
  • Hypotension
  • Confusion
  • Muscle weakness
  • Loss of tendon reflexes

Drug Interactions:

  • Magnesium sulphate potentiates the effects of calcium channel blockers and neuromuscular blockers.
  • Concomitant use with alcohol and other CNS depressants may increase the CNS depressant effects of magnesium sulphate.

Key Issues to Note:

  • IV bolus must be injected slowly to avoid respiratory or cardiac arrest.
  • Discontinue the drug as soon as the needed effect is achieved.
  • When giving repeated doses, test knee jerk reflex before each dose; if absent, discontinue magnesium.

Drugs for Endometriosis

Endometriosis is a medical condition characterized by the growth of endometrial tissue outside the uterine cavity. 

It affects women in their reproductive years. Patients may be asymptomatic or have pelvic pain, menstrual changes, bowel symptoms, or infertility.

Drugs used in the treatment of endometriosis include:

  • Danazol
  • NSAIDs
  • Progesterone
  • Combined oral contraceptives

Danazol

Available Preparations:

  • Capsules: 50 mg, 100 mg, 200 mg

Available Brands: Gonablok®

Pharmacokinetics: It is well absorbed following oral administration, extensively metabolized in the liver, and excreted in urine.

Indications:

  • Endometriosis
  • Benign fibrocystic breast disease
  • Dysfunctional uterine bleeding
  • Prevention of hereditary angioedema
  • Gynaecomastia in males
  • Pre-menstrual syndrome
  • Prolactinomas
  • Female infertility
  • Amenorrhoea
  • Acromegaly

Contraindications:

  • Markedly impaired renal, hepatic, or cardiac function
  • Undiagnosed abnormal vaginal bleeding
  • Pregnancy and lactation
  • Porphyria
  • Androgen tumor
  • History of thromboembolic disease

Dosage:

  • Endometriosis: 100-400 mg twice daily for 3-9 months
  • Benign Breast Disorder: 50-200 mg twice daily, adjusted according to response for 3-6 months
  • Dysfunctional Uterine Bleeding: 200 mg daily for 3-6 months
  • Hereditary Angioedema: 200 mg 2-3 times daily reduced according to patient response
  • Gynaecomastia: 200 mg daily increased after 2 months to 400 mg daily if no response occurs

Side Effects:

  • Acne
  • Oily skin
  • Weight gain
  • Mild hirsutism
  • Nausea
  • Skin rash
  • Menstrual disturbance
  • Hot flashes
  • Changes in libido
  • Oedema
  • Hair loss
  • Headache
  • Backache
  • Tremors
  • Amenorrhoea
  • Sweating
  • Vaginal dryness and irritation
  • Deepening of the voice

Drug Interactions:

  • Warfarin anticoagulant effects may be enhanced by danazol.
  • Danazol may increase the effect of carbamazepine.
  • Danazol may cause decreases in blood glucose levels, which may require adjustment of insulin or oral hypoglycemic drugs.

Key Issues to Note:

  • The drug should not be discontinued without consulting the prescriber.
  • Therapy may take up to several months for full benefit depending on the purpose of treatment.
  • The drug may cause photosensitivity; therefore, avoid direct exposure to sunlight.
  • To treat endometriosis and fibrocystic breast disease, danazol therapy should begin during menstruation.
  • Advise the patient to report voice changes.
  • Advise female patients that amenorrhea usually occurs after 6-8 weeks of therapy.
  • Avoid administration of danazol with a fatty meal.
  • Use non-hormonal contraceptive measures and discontinue the drug if you suspect pregnancy.

Drugs for Contraception

Contraception refers to the various methods used to prevent pregnancy. These methods can be either medical or non-medical and may be used by men, women, or both.

Common methods of contraception include:

  • Abstinence
  • Barrier methods (male and female condoms)
  • Intrauterine devices (IUD)
  • Hormonal contraceptives
  • Female or male sterilization
  • Emergency contraceptives
Oral Contraceptives

Oral contraceptives are divided into two:

  • Combined oral contraceptives
  • Progestogen-only pills

Combined Oral Contraceptives

Oral combined contraceptives contain low doses of estrogen and progesterone. They are the most widely used contraceptives and have the lowest failure rate in terms of unwanted pregnancies. They are suitable for women who regularly experience exceptionally painful, heavy, or prolonged periods.

Mode of Action: They inhibit ovulation, reduce receptivity of endometrium to implantation, and thicken cervical mucus to form a barrier to sperm.

Indications:

  • Contraception
  • Dysfunctional uterine bleeding
  • Dysmenorrhoea
  • Endometriosis
  • Pre-menstrual syndrome
  • Menorrhagia

Contraindications:

  • Pregnancy
  • History of thromboembolic disorder
  • Pulmonary hypertension
  • Active viral hepatitis
  • Unexplained uterine bleeding
  • History of breast or hepatic cancer
  • Migraine
  • Atrial fibrillation
  • Severe cirrhosis

Side Effects:

  • Breakthrough bleeding
  • Changes in weight
  • Changes in libido
  • Venous thromboembolism
  • Fluid retention
  • Amenorrhoea
  • Photosensitivity
  • Breast enlargement and tenderness
  • Nausea and vomiting
  • Depression
  • Acne
  • Cervical cancer
  • Headache
  • Stroke

  • Increased blood pressure

Examples of Combined Oral Contraceptives:

MICROGYNON®/NEF®:

  • Composition: Levonorgestrel 0.15 mg, Ethinylestradiol 0.03 mg, Ferrous fumarate 75 mg (7 brown tablets)
  • Dosage: 1 tablet daily for 28 days starting on day 1 of the menstruation cycle with the active tablets.

PILL PLAN®:

  • Composition: Norgestrel 0.3 mg, Ethinylestradiol 0.03 mg, Ferrous fumarate 75 mg (7 brown tablets)
  • Dosage: 1 tablet daily for 28 days starting on day 1 of the menstruation cycle with the active tablets.

LO-FEMENAL®:

  • Composition: Norgestrel 0.3 mg, Ethinylestradiol 0.03 mg, Ferrous fumarate 75 mg (7 brown tablets)
  • Dosage: 1 tablet daily starting on day 1 of the menstruation cycle with the active tablets.

Progestogen-Only Pills

Progestogen-only pills are often recommended for women who react to estrogen in the combined pill or where combined pills are not suitable because of age or medical history. They may be used by breastfeeding mothers since they do not affect the quantity and quality of the milk produced. Progestogen-only pills have a higher failure rate compared to combined pills and must be taken at the same time each day for maximum contraceptive effect.

Mode of Action: Progestogen thickens the cervical mucus, which impedes the passage of sperm, disrupts the menstrual cycle including preventing the release of the eggs from the ovaries, and changes the endometrium reducing the potential for implantation.

Indications:

  • Contraception
  • Emergency contraception
  • Endometriosis
  • Menstrual disorders

Contraindications:

  • Pregnancy
  • Undiagnosed vaginal bleeding
  • Porphyria
  • Active viral hepatitis
  • Breast or liver cancer
  • Severe arterial disease

  • Severe cirrhosis

Side Effects:

  • Nausea
  • Spotting
  • Dizziness
  • Breast discomfort
  • Depression
  • Amenorrhoea
  • Vomiting
  • Weight gain
  • Headache
  • Prolonged bleeding
  • Acne

Examples:

OVRETTE®:

  • Composition: Norgestrel 0.075 mg
  • Dosage: 1 tablet daily starting on day 1 of the menstruation cycle.

SOFT SURE®:

  • Composition: Levonorgestrel 0.03 mg
  • Dosage: 1 tablet daily at the same time each day.
Emergency Contraceptives

Emergency contraceptives are effective if the dose is taken ideally within 12 hours but not later than 72 hours of unprotected intercourse.

Examples:

POSTINOR®:

  • Composition: Levonorgestrel 0.75 mg
  • Dosage: 1.5 mg (2 tablets) as a single dose as soon as possible within 12 hours but not later than 72 hours.

POSTINOR-2®:

  • Composition: Levonorgestrel 0.75 mg
  • Dosage: 1.5 mg (2 tablets) as a single dose as soon as possible within 12 hours but not later than 72 hours.

Parenteral Progestogen-Only Contraceptives

Parenteral progestogen-only contraceptives provide reliable suppression of ovulation by suppressing the luteinizing hormone.

Indications:

  • Contraception

Side Effects:

  • Menstrual irregularities
  • Spotting
  • Breast tenderness
  • Loss of bone mineral density
  • Prolonged bleeding
  • Amenorrhoea
  • Weight gain

Contraindications:

  • History of breast cancer
  • Pregnancy

Examples:

  • Medroxyprogesterone

Medroxyprogesterone

Available Preparations:

  • 150 mg/ml

Available Brands: Depo-Provera, Injecta Plan

Dosage:

  • By deep intramuscular injection: 150 mg within the first 5 days of the cycle, repeated every 12 weeks (3 months).

Drugs Used in the Treatment of Obstetric and Gynecological Disorders Read More »

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