I. DISEASE 1. Tuberculosis Other names: Koch’s Disease Consumption Phthisis Weak lungs CAUSATIVE AGENT Mycobacterium tuberculosis TB bacillus Koch’s bacillus Mycobacterium bovis (rod-shaped) Incubation period : 4 – 6 weeks MODE OF TRANSMISSION Airborne-droplet Direct invasion through mucous membranes and breaks in the skin (very rare) EPI DISEASES

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

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

TREATMENT: SCC/Short Course Chemotherapy, Direct –observed treatment short course/DOTS; Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S) CATEGORY 1: 6 months SCC Indications: > new (+) smear > (-) smear PTB with extensive parenchymal lesions on CXR > Extrapulmonary TB > severe concominant HIV disease Intensive Phase: 2 months R&I : 1 tab each; P&E 2 tabs each Continuation Phase: 4 months R&I : 1 tab each
CATEGORY 2: 8 months SCC Indications: > treatment failure > relapse > return after default Intensive Phase:3 mos R&I 1 tab each; P&E 2 tabs each Streptomycin – 1 vial/day IM for first 2 months = 56 vials (if given for > 2mos can cause nephrotoxicity Continuation Phase: 5 months R&I : 1 tab each E : 2 tabs

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

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

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

• Respiratory precautions • Cover the mouth and nose when sneezing to avoid mode of transmission • Give BCG • Improve social conditions

SIDE EFFECTS: Ethambutol • Optic neuritis • Blurring of vision (Not to be givento children below 5 y.o. due to inability to complain blurring of vision) • Inability to recognize green from blue Streptomycin • Damage to 8th CN • Ototoxic • Tinnitus • nephrotoxic

6 NATIONAL TB CONTROL PROGRAM: Vision: A country where TB is no longer a public health problem Mission: Ensure that TB DOTS Services are available, accessible, and affordable to the communities in collaboration with LGUs and others Goal: To reduce prevalence and mortality from TB by half by the year 2015 (Millennium Development Goal) Targets: 1. Cure at least 85% of the sputum smear (+) patients discovered 2. Detect at least 70% new sputum smear (+) TB cases Objectives: 1. Improve access to and quality of services 2. Enhance stakeholder’s health-seeking behavior 3. Increase and sustain support for TB control activities 4. Strengthen management of TB control activities at all levels KEY POLICIES: *Case finding: - DSSM shall be the primary diagnostic tool in NTP case finding - No TB Dx shall be made based on CXR results alone - All TB symptomatic shall be asked to undergo DSSM before treatment - Only contraindication for sputum collection is hemoptysis - PTB symptomatic shall be asked to undergo other tests (CXR and culture), only after three sputum specimens yield negative results in DSSM - Only trained med techs / microscopists shall perform DSSM - Passive case finding shall be implemented in all health stations *Treatment: Domiciliary treatment – preferred mode of care DSSM – basis for treatment of all TB cases *Hospitalization is recommended: massive hemoptysis, pleural effusion, military TB, TB meningitis, TB pneumonia, & surgery is needed or with complications *All patients undergoing treatment shall be supervised *National & LGUs shall ensure provision of drugs to all smear (+) TB cases *Quality of fixed-dose combination (FDC) must be ensured *Treatment shall be based on recommended category of treatment regimen DOTS Strategy – internationally-recommended TB control strategy Five Elements of DOTS: (RUSAS) Recording & reporting system enabling outcome assessment of all patients Uninterrupted supply of quality-assured drugs Standardized SCC for all TB cases Access to quality-assured sputum microscopy Sustained political commitment

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s MANAGEMENT OF CHILDREN WITH TUBERCULOSIS - for TB symptomatic children *a TB symptomatic child with either known or Prevention: BCG immunization to all infants (EPI) unknown exposure to a TB case shall be referred for tuberculin testing Casefinding: * (+) contact but (-) tuberculin test and unknown - cases of TB in children are reported and identified in 2 contact but (+) tuberculin test shall be referred for instances: (a) patient was screened and was found symptomatic CXR examination of TB after consultaion (b) patient was reported to have been *(-) CXR, repeat tuberculin test after 3 months exposed to an adult TB patient * INH chemoprophylaxis for three months shall be - ALL TB symptomatic children 0-9 y.o, EXCEPT sputum given to children less than 5y.o. with (-) CXR; after positive child shall be subjected to Tuberculin testing (Note: which tuberculin test shall be repeated Only a trained PHN or main health center midwife shall do tuberculin testing and reading which shall be conducted once a Treatment (Child with TB): week either on a Monday or Tuesday. Ten children shall be Short course regimen gathered for testing to avoid wastage. PULMONARY TB Intensive: 3 anti-TB drugs (R.I.P.) for 2 months - Criteria to be TB symptomatic (any three of the following:) Continuation: 2 anti-TB drugs (R&I) for 4 months * cough/wheezing of 2 weeks or more * unexplained fever of 2 weeks or more EXTRA-PULMONARY TB * loss of appetite/loss of weight/failure to gain weight/weight Intensive: 4 anti-TB drugs (RIP&E/S) for 2 months faltering Continuation: 2 anti-TB drugs (R&I) for 10 months * failure to respond to 2 weeks of appropriate antibiotic therapy for lower respiratory tract infection * failure to regain previous state of health 2 weeks after a viral infection or exanthem (e.g. measles)

-Conditions confirming TB diagnosis (any 3 of the following:) * (+) history of exposure to an adult/adolescent TB case * (+) signs and symptoms suggestive of TB * (+) tuberculin test * abnormal CXR suggestive of TB * Lab findings suggestive or indicative of TB - for children with exposure to TB * a child w/ exposure to a TB registered adult patient shall undergo physical exam and tuberculin testing * a child with productive cough shall be referred for sputum exam, for (+) sputum smear child, start treatment immediately * TB asymptomatic but (+) tuberculin test and TB symptomatic but (-) tuberculin test shall be referred for CXR examination

2. Diphtheria Types: > nasal > pharyngeal – most common > laryngeal – most fatal due to proximity to epiglottis Corynebacterium diphtheria Klebbs-loffler Droplet especially secretions from mucous membranes of the nose and nasopharynx and from skin and other lesions Milk has served as a vehicle Incubation Period: 2 – 5 days Droplet especially from laryngeal and bronchial secretions Incubation Period: 7 – 10 days but not exceeding 21 days (because if more than 21 days, the cough can be related to TB or lung cancer) Indirect contact – inanimate objects, soil, street dust, animal and human feces, punctured wound Risus sardonicus (Latin: “devil smile”) – facial spasm; sardonic grin Opisthotonus – arching of back For newborn: 1. Difficulty of sucking 2. Excessive crying 3. Stiffness of jaw 4. Body malaise Paralysis Muscular weakness Uncoordinated body movement Hoyne’s sign – head lag after 4 months (!Safety) Pseudomembrane – mycelia of the oral mucosa causing formation of white membrane on the oropharynx Bull neck Dysphagia Dyspnea

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Diagnostic test: • Nose/throat swab • Moloney’s test – a test for hypersensitivity to diphtheria toxin • Schick’s test – determines susceptibility to bacteria Drug-of-Choice: Erythromycin 20,000 - 100,000 units IM once only Complication: MYOCARDITIS (Encourage bed rest) Catarrhal period: 7 days paroxysmal cough followed by continuous nonstop accompanied by vomiting Complication: abdominal hernia Diagnostic: • Bordet-gengou agar test Management: 1. DOC: Erythromycin or Penicillin 20,000 - 100,000 units 2. Complete bed rest 3. Avoid pollutants 4. Abdominal binder to prevent abdominal hernia DPT immunization Booster: 2 years and 4-5 years Patient should be segregated until after 3 weeks from the appearance of paroxysmal cough DPT immunization Pasteurization of milk Education of parents

3. Pertussis Whooping cough Tusperina No day cough

Bordetella pertussis Hemophilus pertussis Bordet-gengou bacillus Pertussis bacillus

Incidence: highest under 7 years of age Mortality: highest among infants (<6 months) 4. Tetanus confers definite and prolonged Clostridium tetani – anaerobic One attack spore-forming heat-resistant immunity. Second attack occasionally occurs and
Other names: Lock jaw lives in soil or intestine

No specific test, only a history of punctured wound Treatment: Antitoxin antitetanus serum (ATS) tetanus immunoglobulin (TIG) Pen G Diazepam – for muscle spasms Note: The nurse can give fluid provided that the patient is able to swallow. There is risk of aspiration. Check first for the gag reflex Diagnostic test: • CSF analysis / lumbar tap • Pandy’s test Management: Rehabilitation involves ROM exercises

DPT immunization Tetanus toxoid immunization among pregnant women Licensing of midwives Health education of mothers

Neonate: umbilical cord Children: dental caries Adult: punctured wound; after septic abortion

5. Poliomyelitis Other name: Infantile paralysis

Legio debilitans Polio virus Enterovirus Attacks the anterior horn of the neuron, motor is affected Man is the only reservoir

Incubation Period: Varies from 3 days to 1 month, falling between 7 – 14 days Fecal – oral route Incubation period: 7 – 21 days

OPV vaccination Frequent hand washing

6. Measles Other names: Morbilli Rubeola RNA containing paramyxovirus Droplet secretions from nose and throat Incubation period: 10 days – fever 14 days – rashes appear Period of Communicability: 4 days before and 5 days after the appearance of rash 1. Koplik’s spots – whitish/bluish pinpoint patches on the buccal cavity 2. cephalocaudal appearance of maculopapular rashes 3. Stimson’s line – bilateral red line on the lower conjunctiva

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No specific diagnostic test Management: Supportive and symptomatic Measles vaccine Disinfection of soiled articles Isolation of cased from diagnosis until about 5-7 days after onset of rash

7. Hepatitis B Other names: Serum Hepatitis

Hepatitis B virus

Blood and body fluids Placenta Incubation period: 45 – 100 days

1. Right-sided Abdominal pain
2. 3. 4. 5. Jaundice Yellow-colored sclera Anorexia Nausea and vomiting 6. Joint and Muscle pain 7. Steatorrhea 8. Dark-colored urine 9. Low grade fever

Diagnostic test: • Hepatitis B surface agglutination (HBSAg) test Management: > Hepatitis B Immunoglobulin Diet: high in carbohydrates

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

Hepatitis A – infectious hepatitis; oral-fecal Hepatitis B – serum hepatitis; blood and body fluids Hepatitis C – non-A non-B, post-transfusion hepatitis; blood and body fluids Hepatitis D – Delta hepatitis or dormant hepatitis; blood and body fluids; needs past history of infection to Hepatitis B Hepatitis E – oral-fecal II. DISEASES TRANSMITTED THROUGH FOOD AND WATER DISEASE 1. Cholera Other names: El tor CAUSATIVE AGENT Vibrio cholera Vibrio coma Ogawa and Inaba bacteria MODE OF TRANSMISSION Fecal-oral route 5 Fs Incubation Period: Few hours to 5 days; usually 3 days 2. Amoebic Dysentery Entamoeba histolytica Protozoan (slipper-shaped body) Fecal-oral route PATHOGNOMONIC SIGN Rice watery stool Period of Communicability: 7-14 days after onset, occasionally 2-3 months MANAGEMENT/TREATMENT Diagnostic Test: Stool culture Treatment: Oral rehydration solution (ORESOL) IVF Drug-of-Choice: tetracycline (use straw; can cause staining of teeth) Treatment: Metronidazole (Flagyl) * Avoid alcohol because of its Antabuse effect can cause PREVENTION Proper handwashing Proper food and water sanitation Immunization of Chole-vac

• Abdominal cramping • Bloody mucoid stool • Tenesmus - feeling of

Proper handwashing Proper food and water sanitation

incomplete defecation (Wikipedia) 3. Shigellosis Other names: Bacillary dysentery Shigella bacillus Sh-dysenterae – most infectious Sh-flesneri – common in the Philippines Sh-connei Sh-boydii Salmonella typhosa (plural, typhi) Fecal-oral route 5 Fs: Finger, Foods, Feces, Flies, Fomites Incubation Period: 1 day, usually less than 4 days Fecal-oral route 5 Fs Incubation Period: Usual range 1 to 3 weeks, average 2 weeks Fecal-oral route 5 Fs Incubation Period: 15-50 days, depending on dose, average 20-30 days Ingestion of raw of inadequately cooked seafood usually bivalve mollusks during red tide season Incubation Period: 30 minutes to several hours after ingestion • Abdominal cramping • Bloody mucoid stool • Tenesmus - feeling of incomplete defecation (Wikipedia) vomiting

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Drug-of-Choice: Co-trimoxazole Diet: Low fiber, plenty of fluids, easily digestible foods

Proper handwashing Proper food and water sanitation Fly control

4. Typhoid fever

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

Diagnostic Test: Typhi dot – confirmatory test; specimen is feces Widal’s test – agglutination of the patient’s serum Drug-of-Choice: Chloramphenicol Prophylaxis: “IM” injection of gamma globulin Hepatitis A vaccine Hepatitis immunoglobulin Complete bed rest – to decrease metabolic needs of liver Low-fat diet; increase carbohydrates (high in sugar) Treatment: 1. No definite treatment 2. Induce vomiting 3. Drink pure coconut milk – weakens the toxic effect 4. Sodium bicarbonate solution (25 grams in ½ glass of water) Advised only in the early stage of illness because paralysis can lead to aspiration NOTE: Persons who survived the first 12 hours after ingestion have a greater chance of survival.

Proper handwashing Proper food and water sanitation

• Ladderlike fever • • • • • • Fever Headache Jaundice Clay-colored stool Lymphadenopathy Anorexia Proper handwashing Proper food and water sanitation Proper disposal of urine and feces Separate and proper cleaning of articles used by patient

5. Hepatitis A Other names: Infectious Hepatitis / Epidemic Hepatitis / Catarrhal Jaundice 6. Paralytic Shellfish Poisoning (PSP I Red tide poisoning)

Hepatitis A Virus

Dinoflagellates Phytoplankton

• Numbness of face especially around the mouth • Vomiting and dizziness • Headache • Tingling sensation/paresthesia and eventful paralysis of hands • Floating sensation and weakness • Rapid pulse • Dysphonia • Dysphagia • Total muscle paralysis leading to respiratory arrest and death

1. Avoid eating shellfish such as tahong, talaba, halaan, kabiya, abaniko during red tide season 2. Don’t mix vinegar to shellfish it will increase toxic effect 15 times greater


III. SEXUALLY TRANSMITTED DISEASES DISEASE 1. Syphilis Other names: Sy Bad Blood The pox Lues venereal Morbus gallicus 2. Gonorrhea Other names: GC, Clap, Drip, Stain, Gleet, Flores Blancas 3. Trichomoniasis Other names: Vaginitis Trich CAUSATIVE AGENT Treponema pallidum (a spirochete) MODE OF TRANSMISSION Direct contact Transplacental Incubation Period: 10 days to 3 months (average of 21 days) PATHOGNOMONIC SIGN Primary stage: painless chancre at site of entry Buboes Condylomata Gumma

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MANAGEMENT/TREATMENT Diagnostic test: Dark field illumination test Fluorescent treponemal antibody absorption test – most reliable and sensitive diagnostic test for Syphilis VDRL slide test, CSF analysis, Kalm test, Wasseman test Treatment: Drug of Choice: Penicillin (Tetracycline if resistant to Penicillin) Diagnostic test: Culture of urethral and cervical smear Gram staining Treatment: Drug of Choice: Penicillin Diagnostic Test: Culture Treatment: Drug of Choice: Metronidazole (Flagyl)

PREVENTION Abstinence Be faithful Condom

Primary and secondary sores will go even without treatment but the germs continue to spread throughout the body. Latent syphilis may continue 5 to 20+ years with NO symptoms, but the person is NO longer infectious to other people. A pregnant Neiserria gonorrheae Direct contact – genitals, Thick purulent yellowish mother can transmit the diseaseanus, mouth to her unborn child (congenital syphilis). discharge
Incubation Period: 2 – 10 days Trichomonas vaginalis Direct contact Incubation Period: 4 – 20 days; average of 7 days Burning sensation upon urination / dysuria Females: white or greenish-yellow odorous discharge vaginal itching and soreness painful urination Males: Slight itching of penis Painful urination Clear discharge from penis Females: Asymptomatic Dyspareunia Fishy vaginal discharge Males: Burning sensation during urination Burning and itching of urethral opening (urethritis) White, cheese-like vaginal discharges Curd like secretions

Abstinence Be faithful Condom

Abstinence Be faithful Condom Personal Hygiene

4. Chlamydia

Chlamydia trachomatis (a rickettsia)

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

Diagnostic Test: Culture Treatment: Drug of Choice: Tetracycline

Abstinence Be faithful Condom

5. Candidiasis Other names: Moniliasis Candidosis

Candida albicans

Direct contact

Diagnostic Test: Culture Gram staining Treatment: Nystatin for oral thrush Cotrimazole, fluconazole for mucous membrane and vaginal infection

Abstinence Be faithful Condom


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Fluconazole or amphotericin for systemic infection

6. Acquired immune deficiency syndrome (AIDS)

Retrovirus (Human T-cell lymphotrophic virus 3 or HTLV 3) Attacks the T4 cells: T-helper cells; T-lymphocytes, and CD4 lymphocytes

Direct contact Blood and body fluids Transplacental Incubation period: 3-6 months to 8-10 years Variable. Although the time from infection to the development of detectable antibodies is generally 1-3 months, the time from HIV infection to diagnosis of AIDS has an observed range of less than 1 year to 15 years or longer. (PHN Book)

1. Window Phase a. initial infection b. lasts 4 weeks to 6 months c. not observed by present laboratory test (test should be repeated after 6 months) 2. Acute Primary HIV Infection a. short, symptomatic period b. flu-like symptoms c. ideal time to undergo screening test (ELISA) 3. Asymptomatic HIV Infection a. with antibodies against HIV but not protective b. lasts for 1-20 years depending upon factors 4. ARC (AIDS Related Complex) a. a group of symptoms indicating the disease is likely to progress to AIDS b. fever of unknown origin c. night sweats d. chronic intermittent diarrhea e. lymphadenopathy f. 10% body weight loss 5. AIDS a. manifestation of severe immunosuppression b. CD4 Count: <200/dL c. presence of variety of infections at one time: oral candidiasis leukoplakia AIDS dementia complex Acute encephalopathy Diarrhea, hepatitis Anorectal disease

Diagnostic tests: Enzyme-Linked Immuno-Sorbent Assay (ELISA) presumptive test Western Blot – confirmatory Treatment: 1. Treatment of opportunistic infection 2. Nutritional rehabilitation 3. AZT (Zidovudine) – retards the replication of retrovirus 4. PK 1614 - mutagen

Abstinence Be faithful Condom Sterilize needles, syringes, and instruments used for cutting operations Proper screening of blood donors Rigid examination of blood and other blood products Avoid oral, anal contact and swallowing of semen Avoid promiscuous sexual contact HIV/AIDS Prevention and Control Program: Goal: Contain the transmission of HIV /AIDS and other reproductive tract infections and mitigate their impact

Cytomegalovirus Pneumonocystis carinii pneumonia (fungal) TB Kaposi’s sarcoma (skin cancer; bilateral purplish patches) Herpes simplex Pseudomonas infection Blindness Deafness

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ROBERT C. REÑA, BS IV. ERUPTIVE DISEASES DISEASE 1. Chickenpox Other names: Varicella CAUSATIVE AGENT Human (alpha) herpes virus 3 (varicella-zoster virus), a member of the Herpesvirus group MODE OF TRANSMISSION Droplet spread Direct contact Indirect through articles freshly soiled by discharges of infected persons Period of Communicability: Not more than one day before and more than 6 days after appearance of the first crop of vesicles Rubella virus or RNAcontaining Togavirus German measles is teratogenic infection. Incubation Period: 2-3 weeks, commonly 13 to 17 days Droplet Incubation Period: Three (3) days Forscheimer spots – red pinpoint patches on the oral cavity Maculopapular rashes Headache Low-grade fever Sore throat Droplet Direct contact from secretion Painful vesiculo-pustular lesions on limited portion of the body (trunk and shoulder) Low-grade fever Classification (WHO): Grade I: a. flu-like symptoms b. Herman’s sign Diagnostic Test: Rubella Titer (Normal value is 1:10) PATHOGNOMONIC SIGN Vesiculo-pustular rashes Centrifugal appearance of rashes Pruritus Drug-of-choice: Acyclovir (orally to reduce the number of lesions; topically to lessen the pruritus) MANAGEMENT/TREATMENT No specific diagnostic exam Treatment is supportive and symptomatic; infection viral in origin, and therefore is self-limiting PREVENTION Case over 15 years of age should be investigated to eliminate possibility of smallpox. Report to local authority Isolation Concurrent disinfection of throat and nose discharges Exclusion from school for 1 week after eruption first appears Avoid contact with susceptibles MMR vaccine (live attenuated virus) - Derived from chick embryo Contraindication: - Allergy to eggs - If necessary, given in divided or fractionated doses and epinephrine should be at the bedside. Avoidance of mode of transmission

2. German Measles Other Names: Rubella Three-day Measles

Instruct the mother to avoid pregnancy for three months after receiving MMR vaccine. Treatment is supportive and symptomatic Acyclovir to lessen the pain Diagnostic Test: Torniquet test (Rumpel Leads Test / capillary fragility test) – PRESUMPTIVE; positive when 20 or more oetechiae per 2.5 cm square or 1 inch square are observed

3. Herpes Zoster Other names: Shingles Cold sores 4. Dengue Hemorrhagic Fever Other names: H-fever

Herpes zoster virus (dormant varicella zoster virus)

Dengue virus 1, 2, 3, and 4 and Chikungunya virus Period of communicability: Unknown. Presumed to be on

Bite of infected mosquito (Aedes Aegypti) Daytime biting Low flying

4 o’clock habit Chemically treated mosquito net Larva eating fish Environmental sanitation

the 1st week of illness up to when the virus is still present in the blood Occurrence is sporadic throughout the year Epidemic usually occur during the rainy seasons (June to November) Peak months: September and October Stagnant clear water Urban Incubation Period: Uncertain. Probably 6 days to 1 week Manifestations: First 4 days: Febrile/Invasive Stage - starts abruptly as fever - abdominal pain - headache - vomiting - conjunctival infection -epistaxis 4th – 7th days: Toxic/Hemorrhagic Stage - decrease in temperature - severe abdominal pain - GIT bleeding - unstable BP (narrowed pulse pressure) - shock - death may occur 7th – 10th days: Recovery/Convalescent Stage - appetite regained - BP stable Grade III: a. manifestations of Grade II plus beginning of circulatory failure b. hypotension, tachycardia, tachypnea Grade IV: a. manifestations of Grade III plus shock (Dengue Shock Syndome) c. (+) tourniquet sign Grade II: a. manifestations of Grade I plus spontaneous bleeding b. e.g. petechiae, ecchymosis purpura, gum bleeding

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Platelet count – CONFIRMATORY; (Normal is 150 - 400 x 103 / mL) Treatment: Supportive and symptomatic Paracetamol for fever Analgesic for pain Rapid replacement of body fluids – most important treatment ORESOL Blood tansfusion Diet: low-fat, low-fiber, non-irritating, non-carbonated. Noodle soup may be given. ADCF (Avoid Dark-Colored Foods) ALERT! No Aspirin Antimosquito soap Neem tree (eucalyptus) Eliminate vector Avoid too many hanging clothes inside the house Residual spraying with insecticide

ROBERT C. REÑA, BSN V. VECTOR-BORNE DISEASES DISEASE 1. Malaria CAUSATIVE AGENT Plasmodium Parasites: Vivax Falciparum (most fatal; most common in the Philippines) Ovale Malariae MODE OF TRANSMISSION Bite of infected anopheles mosquito Night time biting High-flying Rural areas Clear running water PATHOGNOMONIC SIGN Cold Stage: severe, recurrent chills (30 minutes to 2 hours) Hot Stage: fever (4-6 hours) Wet Stage: Profuse sweating - intermittent chills and MANAGEMENT/TREATMENT Early Diagnosis and Prompt Treatment Early diagnosis – identification of a patient with malaria as soon as he is seen through clinical and/or microscopic method Clinical method – based on signs and symptoms of the patient and the history of his having visited a malaria-endemic area Microscopic method – based on the examination of the blood smear of patient through microscope (done by the medical technologist) PREVENTION *CLEAN Technique *Insecticide – treatment of mosquito net *House Spraying (night time fumigation) *On Stream Seeding – construction of bio-ponds for fish propagation (2-4 fishes/m2 for immediate impact; 200-

sweating - anemia / pallor - tea-colored urine - malaise - hepatomegaly - splenomegaly - abdominal pain and enlargement - easy fatigability NURSING CARE: 1. TSB (Hot Stage) 2. Keep patent warm (Cold Stage) 3. Change wet clothing (Wet Stage) 4. Encourage fluid intake 5. Avoid drafts

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QBC/quantitative Buffy Coat – fastest Malarial Smear – best time to get the specimen is at height of fever because the microorganisms are very active and easily identified Chemoprophylaxis Only chloroquine should be given (taken at weekly intervals starting from 1-2 weeks before entering the endemic area). In pregnant women, it is given throughout the duration of pregnancy. Treatment: Blood Schizonticides - drugs acting on sexual blood stages of the parasites which are responsible for clinical manifestations 1. QUININE – oldest drug used to treat malaria; from the bark of Cinchona tree; ALERT: Cinchonism – quinine toxicity 2. CHLOROQUINE 3. PRIMAQUINE 4. FANSIDAR – combination of pyrimethamine and sulfadoxine Diagnosis Physical examination, history taking, observation of major and minor signs and symptoms Laboratory examinations Nocturnal Blood Examination (NBE) – blood are taken from the patient at his residence or in hospital after 8:00 pm Immunochromatographic Test (ICT) – rapid assessment method; an antigen test that can be done at daytime Treatment: Drug-of-Choice: Diethylcarbamazine Citrate (DEC) or Hetrazan 400/ha. for a delayed effect) *On Stream Clearing – cutting of vegetation overhanging along stream banks *Avoid outdoor night activities (9pm – 3am) *Wearing of clothing that covers arms and legs in the evening *Use mosquito repellents *Zooprophylaxis – typing of domestic animals like the carabao, cow, etc near human dwellings to deviate mosquito bites from man to these animals Intensive IEC campaign

2. Filariasis Other names: Elephantiasis Endemic in 45 out of 78 provinces Highest prevalence rates: Regions 5, 8, 11 and CARAGA

Wuchereria bancrofti Brugia malayi Brugia timori – nematode parasites

Bite of Aedes poecillus (primarily) Aedes flavivostris (secondary) Incubation period: 8 – 16 months

Asymptomatic Stage: Presence of microfilariae in the blood but no clinical signs and symptoms of disease Acute Stage: Lymphadenitis Lymphangitis Affectation of male genitalia Chronic Stage: (10-15 years from onset of first attack) Hydrocele Lymphedema Elephantiasis

CLEAN Technique Use of mosquito repellents Anytime fumigation Wear a long sleeves, pants and socks

3. Shistosomiasis Other Names: Snail Fever Bikharziasis Endemic in 10 regions and 24 provinces

Schistosoma mansoni S. haematobium S. japonicum (endemic in the Philippines)

Contact with the infected freshwater with cercaria and penetrates the skin Vector: Oncomelania Quadrasi

Diarrhea Bloody stools Enlargement of abdomen Splenomegaly Hepatomegalu Anemia weakness

Diagnostic Test: COPT or cercum ova precipitin test Treatment: Drug-of-Choice: PRAZIQUANTEL (Biltracide) Oxamniquine for S. mansoni Metrifonate for S. haematobium

Dispose the feces properly not reaching body of water Use molluscides Prevent exposure to contaminated water (e.g. use rubber boots) Apply 70% alcohol immediately to skin to kill surface cercariae Allow water to stand 48-72

High prevalence: Regions 5, 8, 11

Communicable Disease Nursing
hours before use



VI. DISEASES TRANSMITTED BY ANIMALS DISEASE 1. Leptospirosis Other Names: - Weil’s Disease - Mud Fever - Trench Fever - Flood Fever - Spirochetal Jaundice - Japanese Seven Days fever CAUSATIVE AGENT Leptospira interrogans – bacterial spirochete RAT is the main host. Although pig, cattle, rabbits, hare, skunk, and other wild animals can also serve as reservoir Occupational disease affecting veterinarians, miners, farmers, sewer workers, abattoir workers, etc MODE OF TRANSMISSION Through contact of the skin, especially open wounds with water, moist soil or vegetation infected with urine of the infected host Incubation Period: 7-19 days, average of 10 days PATHOGNOMONIC SIGN Leptospiremic Phase - leptospires are present in blood and CSF - onset of symptoms is abrupt - fever - headache - myalgia - nausea - vomiting - cough - chest pain Immune Phase - correlates with the appearance of circulating IgM Sense of apprehension Headache Fever Sensory change near site of animal bite Spasms of muscles of deglutition on attempts to swallow Fear of water/hydrophobia Paralysis Delirium Convulsions “FATAL once signs and symptoms appear” MANAGEMENT/TREATMENT Diagnosis Clinical manifestations Culture of organism Examination of blood and CSF during the first week of illness and urine after the 10th day Leptospira agglutination test Treatment: Penicillins and other related B-lactam antibiotics Tetracycline (Doxycycline) Erythromycin PREVENTION Protective clothing, boots and gloves Eradication of rats Segregation of domestic animals Awareness and early diagnosis Improved education of people

2. Rabies Other Names: Lyssa Hydrophobia Le Rage

Rhabdovirus of the genus lyssavirus Degeneration and necrosis of brain – formation of negri bodies Two kinds of Rabies: a. Urban or canine – transmitted by dogs b. Sylvatic – disease of wild animals and bats which sometimes spread to dogs, cats, and livestock

Bite or scratch (very rare) of rabid animal Non-bite means: leaking, scratch, organ transplant (cornea), inhalation/airborne (bats) Source of infection: saliva of infected animal or human Incubation period: 2 – 8 weeks, can be years depending on severity of wounds, site of wound as distance from brain, amount of virus introduced, and protection provided by

Diagnosis: history of bite of animal culture of brain of rabid animal demonstration of negri bodies Management: *Wash wound with soap immediately. Antiseptics e.g. povidone iodine or alcohol may be applied *Antibiotics and anti-tetanus immunization *Post exposure treatment: local wound treatment, active immunization (vaccination) and passive immunization (administration of rabies immunoglobulin) *Consult a veterinarian or trained personnel to observe the pet for 14 days *Without medical intervention, the rabies victim would usually last only for 2 to 6 days. Death is often due to

Have pet immunized at 3 months of age and every year thereafter Never allow pets to roam the streets Take care of your pet National Rabies Prevention and Control Program Goal: Human rabies is eliminated in the Philippines and the country is declared rabiesfree

3. Bubonic Plague Bacteria (Yersinia pestis) Vector: rat flea VII. DISEASES OF THE SKIN DISEASE 1. Leprosy Other names: Hansenosis Hansen’s disease -an ancient disease and is a leading cause of permanent physical disability among the communicable diseases CAUSATIVE AGENT Mycobacterium leprae MODE OF TRANSMISSION Airborne-droplet Prolonged skin-to-skin contact PATHOGNOMONIC SIGN Early signs: Change in skin color – either reddish or white Loss of sensation on the skin lesion Loss of sweating and hair growth Thickened and painful nerves Muscle weakness or paralysis or extremities Pin and redness of the eyes Nasal obstruction or bleeding Ulcers that do not heal Late Signs: Madarosis Loss of eyebrows Inability to close eyelids (lagophthalmos) Clawing of fingers and toes Contractures Chronic ulcers Sinking of the nosebridge Enlargement of the breast (gynecomastia) clothing Direct contact with the infected tissues of rodents Fever and lyphadenitis

Communicable Disease Nursing
respiratory paralysis. Streptomycin, tetracycline, chloramphenicol Environmental Sanitation

MANAGEMENT/TREATMENT Diagnostic Test: Slit Skin Smear - determines the presence of M. leprae; optional and done only if clinical diagnosis is doubtful to prevent misclassification and wrong treatment Lepromin Test – determines susceptibility to leprosy Treatment: Ambulatory chemotherapy through use of MDT Domiciliary treatment as embodied in RA 4073 which advocates home treatment PAUCIBACILLARY (tuberculoid and indeterminate); noninfectious type Duration of treatment: 6 to 9 months Procedure: Supervised: Rifampicin and Dapsone once a month on the health center supervised by the rural health midwife Self-administered: Dapsone everyday at the client’s house MULTIBACILLARY (lepromatous and borderline); infectious type Duration of treatment: 24-30 months Procedure: Supervised: Rifampicin, Dapsone, and Lamprene (Clofazimine) once a month on the health center supervised by the rural health midwife Self-administered: Dapsone and Lamprene everyday at the client’s house

PREVENTION Avoid prolonged skin-to-skin contact BCG vaccination – practical and effective preventive measure against leprosy Good personal hygiene Adequate nutrition Health education

2. Anthrax Other names: Malignant pustule Malignant edema Woolsorter disease Ragpicker disease Charbon Bacillus anthracis Contact with a. tissues of animals (cattle, sheep, goats, horses, pigs, etc.) dying of the disease b. biting flies that had partially fed on such animals c. contaminated hair, wool, hides or products made from them e.g. drums and brushes d. soil associated with infected animals or contaminated bone meal used in gardening 1. Cutaneous form – most common - itchiness on exposed part - papule on inoculation site - papule to vesicle to eschar - painless lesion 2. Pulmonary form – contracted from inhalation of B. anthracis spores - at onset, resembles common URTI - after 3-5 days, symptoms become acute, with fever, shock, and death 3. Gastrointestinal anthrax – contracted from ingestion of meat from infected animal - violent gastroenteritis - vomiting - bloody stools

Communicable Disease Nursing
Treatment: Penicillin Proper handwahing Immunize with cell-free vaccine prepared from culture filtrate containing the protection antigen Control dust and proper ventilation

Incubation period: few hours to 7 days most cases occur within 48 hours of exposure

3. Scabies

Sarcoptes scabiei An itch mite parasite

Direct contact with infected individuals Incubation Period: 24 hours

Itching When secondarily infected: Skin feels hot and burning When large and severe: fever, headache, and malaise

Diagnosis: Appearance of the lesion Intense itching Finding of causative mite Treatment: (limited entirely to the skin) Examine the whole family before undertaking treatment Benzyl benzoate emulsion (Burroughs, Welcome) – cleaner to use and has more rapid effect Kwell ointment

Personal hygiene Avoid playing with dogs Laundry all clothes and iron Maintain the house clean Environmental sanitation Eat the right kind of food Regular changing of clean clothing, beddings and towels

4. Pediculosis Other name: Phthipiasis

Pediculosis Capitis (head lice) Corporis (body lice) Pubis (crab lice)

Direct contact Common in school age

Itchiness of the scalp

Kwell shampoo (twice a week) One tbsp water + one tbsp vinegar

Proper hygiene


MODE OF TRANSMISSION Fecal-oral route 5 Fs: Finger, Foods, Flies, Fomites Feces,

Communicable Disease Nursing

DISEASE 1. Ascariasis Other names: Roundworm Giant worms 2. Taeniasis Other name: Tape worm 3. Capillariasis Other name: Whip worm 4. Enterobiasis Other name: Pinworm 5. Ancyloclostomiasis Other name: Hookworm

CAUSATIVE AGENT Ascaris lumbricoides (nematode) Taenia solium – pork Taenia saginata – beef Dyphyllobotruim latum – fish

PATHOGNOMONIC SIGN Pot-bellied Voracious eater Thin extremities Muscle soreness Scleral hemorrhage

MANAGEMENT/TREATMENT Diagnostic Test: Fecalysis Treatment: Antihelminthic: Mebendazole / Pyrantel Pamoate Diagnostic Test: Fecalysis Treatment: Antihelminthic: Mebendazole / Pyrantel Pamoate

PREVENTION Proper handwahing

Eating inadequately cooked pork or beef 5 Fs: Finger, Foods, Flies, Fomites Feces,

Proper handwahing Cook pork and beef adequately

Trichuris trichuria Capillararia Philippinensis Enterobium vermicularis

Eating inadequately cooked seafood 5 Fs: Finger, Foods, Flies, Fomites Inhalation of ova Toilet seat Infected bedsheets 5 Fs: Finger, Foods, Flies, Fomites Walking barefooted 5 Fs: Finger, Foods, Flies, Fomites Feces,

Abdominal pain Diarrhea borborygmi Nocturnal anal itchiness

Diagnostic Test: Fecalysis Treatment: Antihelminthic: Mebendazole / Pyrantel pamoate Diagnostic Test: Fecalysis / tape test Treatment: Antihelminthic: Mebendazole / Pyrantel pamoate

Proper handwahing Cook seafoods adequately Proper handwahing Proper disinfection of beddings

Feces, Dermatitis Feces, Anemia Black fishy stool ROBERT C. REÑA, BSN IX. OTHER COMMUNICABLE DISEASES Diagnostic Test: Fecalysis Treatment: Antihelminthic: Mebendazole / Pyrantel pamoate Proper handwahing Avoid walking barefooted

Ancyclostoma duodenal Necatur americanus

DISEASE 1. Pneumonia Types: a. Community Acquired Pneumonia (CAP) b. Hospital / Nosocomial c. Atypical

CAUSATIVE AGENT Bacteria: Pneumococcus, streptococcus pneumoniae, staphylococcus aureus, Klebsiella pneumonia (Friedlander’s bacilli) Virus: Haemophilus influenzae Fungi: Pneumonocystis carinii pneumonia

MODE OF TRANSMISSION Droplet Incubation Period: 2 – 3 days

PATHOGNOMONIC SIGN Rusty sputum Fever and chills Chest pain Chest indrawing Rhinitis/common cold Productive cough Fast respiration Vomiting at times Convulsions may occur Flushed face Dilated pupils

MANAGEMENT/TREATMENT Diagnosis: Based on signs and symptoms Dull percussion on affected lung Sputum examination – confirmatory Chest x-ray Management: Bedrest Adequate salt, fluid, calorie, and vitamin intake Tepid sponge bath for fever Frequent turning from side to side

PREVENTION Avoid mode of transmission Build resistance Turn to sides Proper care of influenza cases

Highly colored urine with reduced chlorides and increased urates

Communicable Disease Nursing
Antibiotics based on CARI of the DOH Oxygen inhalation Suctioning Expectorants / mucolytics Bronchodilators Oral/IV fluids CPT Supportive and symptomatic Sedatives – to relieve pain from orchitis Cortisone – for inflammation Diet: Soft or liquid as tolerated Support the scrotum to avoid orchitis, edema, and atrophy Dark glasses for photophobia Supportive and symptomatic Keep patient warm and free from drafts TSB for fever Boil soiled clothing for 30 minutes before laundering Avoid use of common towels, glasses, and eating utensils Cover mouth and nose during cough and sneeze

2. Mumps Other name: Epidemic Parotitis

Mumps virus, a member of family Paramyxoviridae

Direct contact Source of infection: Secretions of mouth and nose Incubation Period: 12 to 26 days, usually 18 days

Painful swelling in front of the ear, angle of the jaws and down the neck Fever Malaise Loss of appetite Swelling of one or both testicles (orchitis) in some boys Sudden onset Fever with chills Headache Myalgia / arthralgia

MMR vaccine Isolate mumps cases

3. Influenza Other name: La Grippe

Influenza virus A – most common B – less severe C – rare Period of Communicability: Probably limited to 3 days from clinical onset Group A beta hemolytic streptococcus Other diseases: Scarlet fever St. Anthony fire Puerperal sepsis Imoetigo Acute glumerulonephritis Rheumatic Heart Disease Meningococcus Neisseria meningitides

Direct contact Droplet infection or by articles freshly soiled with nasopharyngeal discharges Airborne Incubation Period: Short, usually 24 – 72 hours Droplet Complication: Rheumatic Heart Disease

4. Streptococcal sore throat Other name: Pharyngitis Tonsillitis

Sudden onset High grade fever with chills Enlarged and tender cervical lymph nodes Inflamed tonsils with mucopurulent exudates Headache dysphagia A. Sudden Onset - high fever accompanied by chills - sore throat, headache, prostration (collapse) B. entrance into the bloodstream leading to septicemia (meningococcemia) a. rash, petchiae, purpura

Diagnosis: Throat swab and culture Treatment: erythromycin Care: Bed rest Oral hygiene with oral antiseptic or with saline gargle (1 glass of warm water + 1 tsp rock salt) Ice collar Diagnostic Test: Lumbar puncture or Lumbar tap - reveals CSF WBC and protein, low glucose; contraindicated for increased ICP for danger of cranial herniation Hemoculture – to rule out meningococcemia Treatment: Osmotic diuretic (Mannitol) – to reduce ICP and relieve cerebral edema; Alert: fastdrip to prevent crystallization

Avoid mode of transmission

5. Meningitis Other name: Cerebrospinal fever

Direct (Droplet) Incubation Period: 2 - 10 days

Respiratory Isolation

C. Symptoms of menigeal irritation - nuchal rigidity (stiff neck) – earliest sign - Kernig’s sign – when knees are flexed, it cannot be extended - Brudzinski signs – pain on neck flexion with automatoc flexion of the knees - convulsion - poker soine (poker face / flat affect) - Increased ICP (Cushing’s triad: hypertension, bradycardia, bradypnea) and widening pulse pressure

Communicable Disease Nursing
Anti-inflammatory (Dexamethasone) – to relieve cerebral edema Antimicrobial (Penicillin) Anticonvulsany (Diazepam / Valium) Complications: Hydrocephalus Deafness (Refer the child for audiology testing) and mutism Blindness


1. Meningococcemia

Neisseria meningitides

Direct contact with respiratory droplet from nose and throat of infected individuals Incubation Period: 2 – 10 days

2. Severe Acute Respiratory Syndrome / SARS Earliest case: Guangdong Province, China in November 2002 Global outbreak: March 12, 2003 First case in the Philippines: April 11, 2003


Close contact with respiratory droplet secretion from patient Incubation Period: 2 – 10 days

High grade fever in the first 24 hours Hemorrhagic rash – petechiae nuchal rigidity Kernig’s sign Brudzinski sign Shock Death Prodromal Phase: Fever (>38 0C) Chills Malaise Myalgia Headache Infectivity is none to low Respiratory Phase: Within 2-7 days, dry nonproductive cough progressing to respiratory distress

Respiratory isolation within 24 hours Drug-of-Choice: Penicillin

Universal precaution Chemoprophylaxis Proper hand washing

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

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

21 3. Bird Flu Other Name: Avian Flu Influenza Virus H5N1 Contact with infected birds Incubation Period: 3 days, ranges from 2 – 4 days Fever Body weakness and body malaise Cough Sore throat Dyspnea Sore eyes

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

4. Influenza A (H1N1) Other Name: Swine Flu May 21, 2009 – first confirmed case in the Philippines June 11, 2009 - The WHO raises its Pandemic Alert Level to Phase 6, citing significant transmission of the virus.

Influenza Virus A H1N1 This new virus was first detected in people in April 2009 in the United States. Influenza A (H1N1) is fatal to humans

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

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

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

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