You are on page 1of 17

5 Communicable Disease Nursing

I. EPI DISEASES

MODE OF
DISEASE CAUSATIVE AGENT PATHOGNOMONIC SIGN MANAGEMENT/TREATMENT PREVENTION
TRANSMISSION
1. Tuberculosis Mycobacterium tuberculosis Airborne-droplet 1. Usually asymptomatic Diagnostic test: Respiratory precautions
2. Low-grade afternoon fever Sputum examination or the Acid-fast bacilli (AFB) / Cover the mouth and nose
Other names: TB bacillus Direct invasion through 3. Night sweating sputum microscopy when sneezing to avoid
Koch’s Disease Koch’s bacillus mucous membranes and 4. Loss of appetite
1. Confirmatory test mode of transmission
Consumption Mycobacterium bovis breaks in the skin (very 5. Weight loss
Phthisis rare) 6. Easy fatigability – due to 2. Early morning sputum about 3-5 cc Give BCG
Weak lungs (rod-shaped) increased oxygen demand 3. Maintain NPO before collecting sputum Improve social conditions
Incubation period : 7. Temporary amenorrhea 4. Give oral care after the procedure
4 – 6 weeks 8. Productive dry cough 5. Label and immediately send to laboratory
Most hazardous period for development of clinical 9. Hemoptysis 6. If unknown when was the sputum collected,
disease is the first 6-12 months after infection discard
Highest risk of developing disease is children under Chest X-ray is used to:
3years old 1. Determine the clinical activity of TB, whether it is
inactive (in control) or active (ongoing)
TREATMENT: SCC/Short Course Chemotherapy, Direct –observed treatment short course/DOTS; 2. To determine the size of the lesion:
Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S) a. Minimal – very small
b. Moderately advance – lesion is < 4 cm
CATEGORY 1: 6 CATEGORY 2: 8 CATEGORY 3: 6 SIDE EFFECTS: c. Far advance – lesion is > 4 cm
months SCC months SCC months SCC Rifampicin Tuberculin Test – purpose is to determine the history SIDE EFFECTS:
Indications: Indications: Indications: body fluid of exposure to tuberculosis
discoloration Ethambutol
> new (+) smear > treatment failure > new (-) smear PTB Other names:
> relapse hepatotoxic Optic neuritis
> (-) smear PTB with with minimal lesions Mantoux Test – used for single screening, result
> return after default permanent interpreted after 72 hours
Blurring of vision
extensive on CXR (Not to be givento
discoloration of Tine test – used for mass screening read after 48 hours
parenchymal lesions Intensive Phase:3 mos Same meds with
contact lenses Interpretation: children below 5 y.o. due
on CXR R&I 1 tab each; P&E 2 Category 1 to inability to complain
0 - 4 mm induration – not significant
> Extrapulmonary TB tabs each Intensive Phase: 2 Isoniazid 5 mm or more – significant in individuals who are blurring of vision)
> severe concominant Streptomycin – 1 months Peripheral considered at risk; positive for patients who are HIV- Inability to recognize
HIV disease vial/day IM for first 2 R&I 1 tab each; P&E neuropathy positive or have HIV risk factors and are of unknown green from blue
Intensive Phase: 2 months = 56 vials (if 2 tabs each (Give Vit HIV status, those who are close contacts with an active Streptomycin
months given for > 2mos can Continuation Phase: B6/Pyridoxine) case, and those who have chest x-ray results consistent
4 months Damage to 8th CN
R&I : 1 tab each; P&E cause nephrotoxicity with tuberculosis.
2 tabs each R&I 1 tab each Pyrazinamide 10 mm or greater – significant in individuals who Ototoxic
Continuation Phase: 5 hyperuricemia /gouty have normal or mildly impaired immunity Tinnitus
Continuation Phase:
months CATEGORY 4: arthritis (increase fluid nephrotoxic
4 months
R&I : 1 tab each Chronic (*Referral intake)
R&I : 1 tab each E : 2 tabs needed)
6 Communicable Disease Nursing

NATIONAL TB CONTROL PROGRAM: s


MANAGEMENT OF CHILDREN WITH TUBERCULOSIS - for TB symptomatic children
Vision: A country where TB is no longer a public health problem *a TB symptomatic child with either known or
Mission: Ensure that TB DOTS Services are available, accessible, and
Prevention: BCG immunization to all infants (EPI) unknown exposure to a TB case shall be referred
affordable to the communities in collaboration with LGUs and others
for tuberculin testing
Goal: To reduce prevalence and mortality from TB by half by the year 2015
(Millennium Development Goal) Casefinding: * (+) contact but (-) tuberculin test and unknown
Targets: 1. Cure at least 85% of the sputum smear (+) patients discovered - cases of TB in children are reported and identified in 2 contact but (+) tuberculin test shall be referred for
2. Detect at least 70% new sputum smear (+) TB cases instances: (a) patient was screened and was found symptomatic CXR examination
Objectives: 1. Improve access to and quality of services of TB after consultaion (b) patient was reported to have been *(-) CXR, repeat tuberculin test after 3 months
2. Enhance stakeholder’s health-seeking behavior exposed to an adult TB patient * INH chemoprophylaxis for three months shall be
3. Increase and sustain support for TB control activities - ALL TB symptomatic children 0-9 y.o, EXCEPT sputum given to children less than 5y.o. with (-) CXR; after
4. Strengthen management of TB control activities at all levels positive child shall be subjected to Tuberculin testing (Note: which tuberculin test shall be repeated
KEY POLICIES: Only a trained PHN or main health center midwife shall do
*Case finding: tuberculin testing and reading which shall be conducted once a Treatment (Child with TB):
- DSSM shall be the primary diagnostic tool in NTP case finding week either on a Monday or Tuesday. Ten children shall be Short course regimen
- No TB Dx shall be made based on CXR results alone gathered for testing to avoid wastage. PULMONARY TB
- All TB symptomatic shall be asked to undergo DSSM before treatment Intensive: 3 anti-TB drugs (R.I.P.) for 2 months
- Only contraindication for sputum collection is hemoptysis - Criteria to be TB symptomatic (any three of the following:) Continuation: 2 anti-TB drugs (R&I) for 4 months
- PTB symptomatic shall be asked to undergo other tests (CXR and culture), * cough/wheezing of 2 weeks or more
only after three sputum specimens yield negative results in DSSM * unexplained fever of 2 weeks or more EXTRA-PULMONARY TB
- Only trained med techs / microscopists shall perform DSSM * loss of appetite/loss of weight/failure to gain weight/weight Intensive: 4 anti-TB drugs (RIP&E/S) for 2 months
- Passive case finding shall be implemented in all health stations faltering Continuation: 2 anti-TB drugs (R&I) for 10 months
* failure to respond to 2 weeks of appropriate antibiotic therapy
*Treatment: Domiciliary treatment – preferred mode of care
for lower respiratory tract infection
DSSM – basis for treatment of all TB cases
* failure to regain previous state of health 2 weeks after a viral
*Hospitalization is recommended: massive hemoptysis, pleural effusion,
military TB, TB meningitis, TB pneumonia, & surgery is needed or with infection or exanthem (e.g. measles)
complications
*All patients undergoing treatment shall be supervised -Conditions confirming TB diagnosis (any 3 of the following:)
*National & LGUs shall ensure provision of drugs to all smear (+) TB cases * (+) history of exposure to an adult/adolescent TB case
*Quality of fixed-dose combination (FDC) must be ensured * (+) signs and symptoms suggestive of TB
*Treatment shall be based on recommended category of treatment regimen * (+) tuberculin test
* abnormal CXR suggestive of TB
DOTS Strategy – internationally-recommended TB control strategy * Lab findings suggestive or indicative of TB
Five Elements of DOTS: (RUSAS)
Recording & reporting system enabling outcome assessment of all patients - for children with exposure to TB
Uninterrupted supply of quality-assured drugs * a child w/ exposure to a TB registered adult patient shall
Standardized SCC for all TB cases undergo physical exam and tuberculin testing
Access to quality-assured sputum microscopy * a child with productive cough shall be referred for sputum
Sustained political commitment 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
7 Communicable Disease Nursing

2. Diphtheria Corynebacterium diphtheria Droplet especially Pseudomembrane – mycelia of Diagnostic test: DPT immunization
secretions from mucous the oral mucosa causing Pasteurization of milk
Types: Klebbs-loffler membranes of the nose formation of white membrane on Nose/throat swab Education of parents
> nasal and nasopharynx and the oropharynx Moloney’s test – a test for hypersensitivity to diphtheria
> pharyngeal – most from skin and other toxin
common lesions Bull neck Schick’s test – determines susceptibility to bacteria
> laryngeal – most Dysphagia
fatal due to proximity Milk has served as a Dyspnea Drug-of-Choice:
to epiglottis vehicle Erythromycin 20,000 - 100,000 units IM once only

Incubation Period: Complication: MYOCARDITIS (Encourage bed rest)


2 – 5 days
3. Pertussis Bordetella pertussis Droplet especially from Catarrhal period: 7 days Diagnostic: DPT immunization
Hemophilus pertussis laryngeal and bronchial paroxysmal cough followed by Booster: 2 years and 4-5 years
Whooping cough Bordet-gengou bacillus secretions continuous nonstop Bordet-gengou agar test Patient should be segregated until
Tusperina Pertussis bacillus accompanied by vomiting after 3 weeks from the
No day cough Incubation Period: 7 – Management: appearance of paroxysmal cough
10 days but not Complication: abdominal hernia 1. DOC: Erythromycin or Penicillin 20,000 - 100,000 units
exceeding 21 days 2. Complete bed rest
3. Avoid pollutants
(because if more than 21 4. Abdominal binder to prevent abdominal hernia
days, the cough can be
Incidence: highest under 7 years of age related to TB or lung
Mortality: highest among infants (<6 months) cancer)
4. Tetanus Clostridium tetani – anaerobic Indirect contact – Risus sardonicus (Latin: “devil No specific test, only a history of punctured wound DPT immunization
One attack confers definite and prolonged
spore-forming heat-resistant and inanimate objects, soil, smile”) – facial spasm; sardonic
immunity.
Other names:Second attack occasionally occurs
lives in soil or intestine street dust, animal and grin Treatment: Tetanus toxoid immunization
Lock jaw human feces, punctured Antitoxin among pregnant women
wound Opisthotonus – arching of back antitetanus serum (ATS)
Neonate: umbilical cord tetanus immunoglobulin (TIG) Licensing of midwives
Children: dental caries For newborn: Pen G
Adult: punctured wound; after 1. Difficulty of sucking Diazepam – for muscle spasms Health education of mothers
septic abortion Incubation Period: 2. Excessive crying
Varies from 3 days to 1 3. Stiffness of jaw Note: The nurse can give fluid provided that the patient is able
month, falling between 7 4. Body malaise to swallow. There is risk of aspiration. Check first for the gag
– 14 days reflex
5. Poliomyelitis Legio debilitans Fecal – oral route Paralysis Diagnostic test: OPV vaccination
Polio virus Muscular weakness Frequent hand washing
Other name: Enterovirus Incubation period: 7 – Uncoordinated body movement CSF analysis / lumbar tap
Infantile paralysis 21 days Hoyne’s sign – head lag after 4 Pandy’s test
Attacks the anterior horn of the months
neuron, motor is affected Management:
Man is the only reservoir (!Safety) Rehabilitation involves ROM exercises
8 Communicable Disease Nursing

6. Measles RNA containing paramyxovirus Droplet secretions from 1. Koplik’s spots – No specific diagnostic test Measles vaccine
nose and throat whitish/bluish pinpoint patches Disinfection of soiled articles
Other names: on the buccal cavity Management: Isolation of cased from diagnosis
Morbilli Incubation period: 10 2. cephalocaudal appearance of Supportive and symptomatic until about 5-7 days after onset of
Rubeola days – fever maculopapular rashes rash
14 days – rashes appear 3. Stimson’s line – bilateral red
line on the lower conjunctiva
Period of
Communicability:
4 days before and 5 days
after the appearance of
rash

7. Hepatitis B Hepatitis B virus Blood and body fluids 1. Right-sided Abdominal pain Diagnostic test: -Hepatitis B immunization
Placenta 2. Jaundice -Wear protected clothing
Other names: 3. Yellow-colored sclera Hepatitis B surface agglutination (HBSAg) test -Hand washing
Serum Hepatitis Incubation period: 4. Anorexia -Observe safe-sex
45 – 100 days 5. Nausea and vomiting Management: -Sterilize instruments used in
6. Joint and Muscle pain > Hepatitis B Immunoglobulin minor surgical-dental procedures
7. Steatorrhea -Screening of blood products for
8. Dark-colored urine Diet: high in carbohydrates transfusion
9. Low grade fever
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

MODE OF
DISEASE CAUSATIVE AGENT PATHOGNOMONIC SIGN MANAGEMENT/TREATMENT PREVENTION
TRANSMISSION
1. Cholera Vibrio cholera Fecal-oral route Rice watery stool Diagnostic Test: Proper handwashing
Vibrio coma Stool culture Proper food and water sanitation
Other names: Ogawa and Inaba bacteria 5 Fs Period of Communicability: Immunization of Chole-vac
El tor 7-14 days after onset, Treatment:
Incubation Period: occasionally 2-3 months Oral rehydration solution (ORESOL)
Few hours to 5 days; IVF
usually 3 days Drug-of-Choice: tetracycline (use straw; can cause staining of
teeth)
2. Amoebic Dysentery Entamoeba histolytica Fecal-oral route Abdominal cramping Treatment: Proper handwashing
Bloody mucoid stool Proper food and water sanitation
Protozoan (slipper-shaped body) Tenesmus - feeling of Metronidazole (Flagyl)
incomplete defecation * Avoid alcohol because of its Antabuse effect can cause
9 Communicable Disease Nursing

(Wikipedia) vomiting

3. Shigellosis Shigella bacillus Fecal-oral route Abdominal cramping Drug-of-Choice: Co-trimoxazole Proper handwashing
Bloody mucoid stool Proper food and water sanitation
Other names: Sh-dysenterae – most infectious 5 Fs: Finger, Foods, Tenesmus - feeling of Diet: Low fiber, plenty of fluids, easily digestible foods Fly control
Bacillary dysentery Sh-flesneri – common in the Feces, Flies, Fomites incomplete defecation
Philippines (Wikipedia)
Sh-connei Incubation Period:
Sh-boydii 1 day, usually less than 4
days
4. Typhoid fever Salmonella typhosa (plural, Fecal-oral route Rose Spots in the abdomen – Diagnostic Test: Proper handwashing
typhi) due to bleeding caused by Typhi dot – confirmatory test; specimen is feces Proper food and water sanitation
5 Fs perforation of the Peyer’s Widal’s test – agglutination of the patient’s serum
patches
Incubation Period: Drug-of-Choice: Chloramphenicol
Usual range 1 to 3 Ladderlike fever
weeks, average 2 weeks
5. Hepatitis A Hepatitis A Virus Fecal-oral route Fever Prophylaxis: “IM” injection of gamma globulin Proper handwashing
Headache Hepatitis A vaccine Proper food and water sanitation
Other names: 5 Fs Jaundice Hepatitis immunoglobulin Proper disposal of urine and feces
Infectious Hepatitis / Clay-colored stool Separate and proper cleaning of
Epidemic Hepatitis / Incubation Period: Lymphadenopathy Complete bed rest – to decrease metabolic needs of liver articles used by patient
Catarrhal Jaundice 15-50 days, depending Anorexia Low-fat diet; increase carbohydrates (high in sugar)
on dose, average 20-30
days
6. Paralytic Shellfish Dinoflagellates Ingestion of raw of Numbness of face especially Treatment: 1. Avoid eating shellfish such as
Poisoning (PSP I Red inadequately cooked around the mouth 1. No definite treatment tahong, talaba, halaan,
tide poisoning) Phytoplankton seafood usually bivalve Vomiting and dizziness 2. Induce vomiting kabiya, abaniko during red
mollusks during red tide Headache 3. Drink pure coconut milk – weakens the toxic effect tide season
season Tingling sensation/paresthesia 4. Sodium bicarbonate solution (25 grams in ½ glass of 2. Don’t mix vinegar to
and eventful paralysis of water) shellfish it will increase toxic
Incubation Period: hands Advised only in the early stage of illness because effect 15 times greater
30 minutes to several Floating sensation and paralysis can lead to aspiration
hours after ingestion weakness NOTE: Persons who survived the first 12 hours after ingestion
Rapid pulse have a greater chance of survival.
Dysphonia
Dysphagia
Total muscle paralysis leading
to respiratory arrest and death

ROBERT C. REÑA, BSN


10 Communicable Disease Nursing

III. SEXUALLY TRANSMITTED DISEASES

MODE OF
DISEASE CAUSATIVE AGENT PATHOGNOMONIC SIGN MANAGEMENT/TREATMENT PREVENTION
TRANSMISSION
1. Syphilis Treponema pallidum Direct contact Primary stage: painless chancre Diagnostic test: Abstinence
(a spirochete) Transplacental at site of entry Dark field illumination test Be faithful
Other names: Buboes Fluorescent treponemal antibody absorption test – most Condom
Sy Incubation Period: Condylomata reliable and sensitive diagnostic test for Syphilis
Bad Blood 10 days to 3 months Gumma VDRL slide test, CSF analysis, Kalm test,
The pox (average of 21 days) Wasseman test
Lues venereal
Morbus gallicus Treatment:
Primary and secondary sores will go even without treatment but the germs continue Drug of Choice: Penicillin (Tetracycline if resistant to
to spread throughout the body. Latent syphilis may continue 5 to 20+ years with NO Penicillin)
2. Gonorrhea symptoms, but the person is NODirect
Neiserria gonorrheae longer infectious
contact to other
– genitals, people.
Thick A pregnant
purulent yellowish Diagnostic test: Abstinence
mother can transmit the diseaseanus,
to her unborn child (congenital
mouth dischargesyphilis). Culture of urethral and cervical smear Be faithful
Other names: Burning sensation upon Gram staining Condom
GC, Clap, Drip, Incubation Period: urination / dysuria
Stain, Gleet, 2 – 10 days Treatment:
Flores Blancas Drug of Choice: Penicillin
3. Trichomoniasis Trichomonas vaginalis Direct contact Females: Diagnostic Test: Abstinence
white or greenish-yellow Culture Be faithful
Other names: Incubation Period: odorous discharge Condom
Vaginitis 4 – 20 days; average of 7 vaginal itching and soreness Treatment:
Trich days painful urination Drug of Choice: Metronidazole (Flagyl) Personal Hygiene
Males:
Slight itching of penis
Painful urination
Clear discharge from penis
4. Chlamydia Chlamydia trachomatis Direct contact Females: Diagnostic Test: Abstinence
(a rickettsia) Asymptomatic Culture Be faithful
Incubation Period: Dyspareunia Condom
2 to 3 weeks for males; Fishy vaginal discharge Treatment:
usually no symptoms for Drug of Choice: Tetracycline
females Males:
Burning sensation during
urination
Burning and itching of urethral
opening (urethritis)
5. Candidiasis Candida albicans Direct contact White, cheese-like vaginal Diagnostic Test: Abstinence
discharges Culture Be faithful
Other names: Curd like secretions Gram staining Condom
Moniliasis
Candidosis Treatment:
Nystatin for oral thrush
Cotrimazole, fluconazole for mucous membrane and vaginal
infection
11 Communicable Disease Nursing

Fluconazole or amphotericin for systemic infection

6. Acquired immune Retrovirus (Human Direct contact 1. Window Phase Diagnostic tests: Abstinence
deficiency syndrome T-cell lymphotrophic virus 3 or Blood and body fluids a. initial infection Enzyme-Linked Immuno-Sorbent Assay (ELISA) Be faithful
(AIDS) HTLV 3) Transplacental b. lasts 4 weeks to 6 months - presumptive test Condom
c. not observed by present Western Blot – confirmatory
Attacks the T4 cells: T-helper Incubation period: laboratory test (test should be Sterilize needles, syringes, and
cells; T-lymphocytes, and CD4 3-6 months to 8-10 years repeated after 6 months) Treatment: instruments used for cutting
lymphocytes 1. Treatment of opportunistic infection operations
Variable. Although the 2. Acute Primary HIV 2. Nutritional rehabilitation
time from infection to the Infection 3. AZT (Zidovudine) – retards the replication of Proper screening of blood donors
development of a. short, symptomatic period retrovirus
detectable antibodies is b. flu-like symptoms 4. PK 1614 - mutagen Rigid examination of blood and
generally 1-3 months, the c. ideal time to undergo other blood products
time from HIV infection screening test (ELISA)
to diagnosis of AIDS has Avoid oral, anal contact and
an observed range of less 3. Asymptomatic HIV swallowing of semen
than 1 year to 15 years or Infection
longer. a. with antibodies against HIV Avoid promiscuous sexual
(PHN Book) but not protective contact
b. lasts for 1-20 years depending
upon factors HIV/AIDS Prevention and
Control Program:
4. ARC (AIDS Related
Complex) Goal: Contain the transmission of
a. a group of symptoms HIV /AIDS and other
indicating the disease is likely to reproductive tract infections and
progress to AIDS mitigate their impact
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
12 Communicable Disease Nursing

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

ROBERT C. REÑA, BS
IV. ERUPTIVE DISEASES

MODE OF
DISEASE CAUSATIVE AGENT PATHOGNOMONIC SIGN MANAGEMENT/TREATMENT PREVENTION
TRANSMISSION
1. Chickenpox Human (alpha) herpes virus 3 Droplet spread Vesiculo-pustular rashes No specific diagnostic exam Case over 15 years of age should
(varicella-zoster virus), a be investigated to eliminate
Other names: member of the Herpesvirus Direct contact Centrifugal appearance of rashes Treatment is supportive and symptomatic; infection viral in possibility of smallpox.
Varicella group origin, and therefore is self-limiting Report to local authority
Indirect through articles Pruritus Isolation
freshly soiled by discharges Drug-of-choice: Concurrent disinfection of throat
of infected persons Acyclovir (orally to reduce the number of lesions; topically to and nose discharges
Period of Communicability: lessen the pruritus) Exclusion from school for 1
Not more than one day before Incubation Period: week after eruption first appears
and more than 6 days after 2-3 weeks, commonly 13 to Avoid contact with susceptibles
appearance of the first crop of 17 days
vesicles
2. German Measles Rubella virus or RNA- Droplet Forscheimer spots – red Diagnostic Test: MMR vaccine (live attenuated
containing Togavirus pinpoint patches on the oral Rubella Titer (Normal value is 1:10) virus)
Other Names: Incubation Period: cavity - Derived from chick embryo
Rubella German measles is teratogenic Three (3) days Contraindication:
Three-day Measles infection. Maculopapular rashes - Allergy to eggs
Headache - If necessary, given in divided
Low-grade fever Instruct the mother to avoid pregnancy for three months after or fractionated doses and
Sore throat receiving MMR vaccine. epinephrine should be at the
bedside.
3. Herpes Zoster Herpes zoster virus Droplet Painful vesiculo-pustular lesions Treatment is supportive and symptomatic Avoidance of mode of
(dormant varicella zoster virus) Direct contact from secretion on limited portion of the body transmission
Other names: (trunk and shoulder) Acyclovir to lessen the pain
Shingles
Cold sores Low-grade fever
4. Dengue Dengue virus 1, 2, 3, and 4 and Bite of infected mosquito Classification (WHO): Diagnostic Test: 4 o’clock habit
Hemorrhagic Fever Chikungunya virus (Aedes Aegypti)
Grade I: Torniquet test (Rumpel Leads Test / capillary fragility test) – Chemically treated mosquito net
Other names: Period of communicability: Daytime biting a. flu-like symptoms PRESUMPTIVE; positive when 20 or more oetechiae per 2.5 Larva eating fish
H-fever Unknown. Presumed to be on Low flying b. Herman’s sign cm square or 1 inch square are observed Environmental sanitation
13 Communicable Disease Nursing

the 1st week of illness up to Stagnant clear water c. (+) tourniquet sign Antimosquito soap
when the virus is still present in Urban Platelet count – CONFIRMATORY; (Normal is 150 - 400 x Neem tree (eucalyptus)
the blood Grade II: 103 / mL)
Incubation Period: a. manifestations of Grade I plus Eliminate vector
Occurrence is sporadic Uncertain. Probably 6 days to spontaneous bleeding Treatment: Avoid too many hanging clothes
throughout the year 1 week b. e.g. petechiae, ecchymosis Supportive and symptomatic inside the house
purpura, gum bleeding Paracetamol for fever Residual spraying with
Epidemic usually occur during Manifestations: Analgesic for pain insecticide
the rainy seasons (June to Grade III:
November) First 4 days: a. manifestations of Grade II Rapid replacement of body fluids – most important treatment
Febrile/Invasive Stage plus beginning of circulatory
Peak months: September and - starts abruptly as fever failure ORESOL
October - abdominal pain b. hypotension, tachycardia,
- headache tachypnea Blood tansfusion
- vomiting
- conjunctival infection Grade IV: Diet: low-fat, low-fiber, non-irritating, non-carbonated.
-epistaxis a. manifestations of Grade III Noodle soup may be given. ADCF (Avoid Dark-Colored
plus shock (Dengue Shock Foods)
4th – 7th days: Syndome)
Toxic/Hemorrhagic Stage ALERT! No Aspirin
- 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

ROBERT C. REÑA, BSN


V. VECTOR-BORNE DISEASES

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

sweating for immediate impact; 200-


- anemia / pallor QBC/quantitative Buffy Coat – fastest 400/ha. for a delayed effect)
- tea-colored urine Malarial Smear – best time to get the specimen is at height of *On Stream Clearing – cutting
- malaise fever because the microorganisms are very active and easily of vegetation overhanging along
- hepatomegaly identified stream banks
- splenomegaly
- abdominal pain and Chemoprophylaxis *Avoid outdoor night activities
enlargement Only chloroquine should be given (taken at weekly intervals (9pm – 3am)
- easy fatigability starting from 1-2 weeks before entering the endemic area). In *Wearing of clothing that covers
pregnant women, it is given throughout the duration of arms and legs in the evening
pregnancy. *Use mosquito repellents
NURSING CARE: *Zooprophylaxis – typing of
1. TSB (Hot Stage) Treatment: domestic animals like the
2. Keep patent warm (Cold Blood Schizonticides - drugs acting on sexual blood stages of carabao, cow, etc near human
Stage) the parasites which are responsible for clinical manifestations dwellings to deviate mosquito
3. Change wet clothing (Wet 1. QUININE – oldest drug used to treat malaria; from bites from man to these animals
Stage) the bark of Cinchona tree; ALERT: Cinchonism –
4. Encourage fluid intake quinine toxicity Intensive IEC campaign
5. Avoid drafts 2. CHLOROQUINE
3. PRIMAQUINE
4. FANSIDAR – combination of pyrimethamine and
sulfadoxine
2. Filariasis Wuchereria bancrofti Bite of Aedes poecillus Asymptomatic Stage: Diagnosis CLEAN Technique
Brugia malayi (primarily) Presence of microfilariae in the Physical examination, history taking, observation of major and
Other names: Brugia timori Aedes flavivostris blood but no clinical signs and minor signs and symptoms Use of mosquito repellents
Elephantiasis (secondary) symptoms of disease Anytime fumigation
– nematode parasites Laboratory examinations Wear a long sleeves, pants and
Endemic in 45 out of Incubation period: Acute Stage: Nocturnal Blood Examination (NBE) – blood are taken from socks
78 provinces 8 – 16 months Lymphadenitis the patient at his residence or in hospital after 8:00 pm
Lymphangitis Immunochromatographic Test (ICT) – rapid assessment
Highest prevalence Affectation of male genitalia method; an antigen test that can be done at daytime
rates: Regions 5, 8, 11
and CARAGA Chronic Stage: (10-15 years Treatment:
from onset of first attack) Drug-of-Choice: Diethylcarbamazine Citrate (DEC) or
Hydrocele Hetrazan
Lymphedema
Elephantiasis

3. Shistosomiasis Schistosoma mansoni Contact with the infected Diarrhea Diagnostic Test: Dispose the feces properly not
S. haematobium freshwater with cercaria and Bloody stools COPT or cercum ova precipitin test reaching body of water
Other Names: S. japonicum (endemic in the penetrates the skin Enlargement of abdomen Use molluscides
Snail Fever Philippines) Splenomegaly Treatment: Prevent exposure to
Bikharziasis Vector: Oncomelania Hepatomegalu Drug-of-Choice: PRAZIQUANTEL (Biltracide) contaminated water (e.g. use
Quadrasi Anemia rubber boots)
Endemic in 10 regions weakness Oxamniquine for S. mansoni Apply 70% alcohol immediately
and 24 provinces Metrifonate for S. haematobium to skin to kill surface cercariae
Allow water to stand 48-72
15 Communicable Disease Nursing

High prevalence: hours before use


Regions 5, 8, 11

ROBERT C. REÑA, BSN


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

VI. DISEASES TRANSMITTED BY ANIMALS

MODE OF
DISEASE CAUSATIVE AGENT PATHOGNOMONIC SIGN MANAGEMENT/TREATMENT PREVENTION
TRANSMISSION
1. Leptospirosis Leptospira interrogans – Through contact of the skin, Leptospiremic Phase Diagnosis Protective clothing, boots and
bacterial spirochete especially open wounds with - leptospires are present in Clinical manifestations gloves
Other Names: water, moist soil or blood and CSF Culture of organism
- Weil’s Disease RAT is the main host. Although vegetation infected with urine - onset of symptoms is abrupt Examination of blood and CSF during the first week of illness Eradication of rats
- Mud Fever pig, cattle, rabbits, hare, skunk, of the infected host - fever and urine after the 10th day
- Trench Fever and other wild animals can also - headache Leptospira agglutination test Segregation of domestic animals
- Flood Fever serve as reservoir Incubation Period: - myalgia
- Spirochetal 7-19 days, average of 10 days - nausea Treatment: Awareness and early diagnosis
Jaundice Occupational disease affecting - vomiting Penicillins and other related B-lactam antibiotics
- Japanese Seven veterinarians, miners, farmers, - cough Tetracycline (Doxycycline) Improved education of people
Days fever sewer workers, abattoir workers, - chest pain Erythromycin
etc
Immune Phase
- correlates with the appearance
of circulating IgM
2. Rabies Rhabdovirus of the genus Bite or scratch (very rare) of Sense of apprehension Diagnosis: Have pet immunized at 3
lyssavirus rabid animal Headache history of bite of animal months of age and every year
Other Names: Fever culture of brain of rabid animal thereafter
Lyssa Degeneration and necrosis of Non-bite means: leaking, Sensory change near site of demonstration of negri bodies
Hydrophobia brain – formation of negri bodies scratch, organ transplant animal bite Never allow pets to roam the
Le Rage (cornea), inhalation/airborne Spasms of muscles of Management: streets
Two kinds of Rabies: (bats) deglutition on attempts to *Wash wound with soap immediately. Antiseptics e.g.
a. Urban or canine – transmitted Source of infection: saliva of swallow povidone iodine or alcohol may be applied Take care of your pet
by dogs infected animal or human Fear of water/hydrophobia *Antibiotics and anti-tetanus immunization
Paralysis *Post exposure treatment: local wound treatment, active National Rabies Prevention
b. Sylvatic – disease of wild Incubation period: Delirium immunization (vaccination) and passive immunization and Control Program
animals and bats which 2 – 8 weeks, can be years Convulsions (administration of rabies immunoglobulin) Goal: Human rabies is
sometimes spread to dogs, cats, depending on severity of *Consult a veterinarian or trained personnel to observe the pet eliminated in the Philippines
and livestock wounds, site of wound as “FATAL once signs and for 14 days and the country is declared
distance from brain, amount symptoms appear” rabies-free
of virus introduced, and *Without medical intervention, the rabies victim would
protection provided by usually last only for 2 to 6 days. Death is often due to
16 Communicable Disease Nursing

clothing respiratory paralysis.


3. Bubonic Plague Bacteria (Yersinia pestis) Direct contact with the Fever and lyphadenitis Streptomycin, tetracycline, chloramphenicol Environmental Sanitation
infected tissues of rodents
Vector: rat flea

VII. DISEASES OF THE SKIN

MODE OF
DISEASE CAUSATIVE AGENT PATHOGNOMONIC SIGN MANAGEMENT/TREATMENT PREVENTION
TRANSMISSION
1. Leprosy Mycobacterium leprae Airborne-droplet Early signs: Diagnostic Test: Avoid prolonged skin-to-skin
Change in skin color – either reddish or Slit Skin Smear - determines the presence of M. leprae; contact
Other names: Prolonged skin-to-skin white optional and done only if clinical diagnosis is doubtful to BCG vaccination – practical
Hansenosis contact Loss of sensation on the skin lesion prevent misclassification and wrong treatment and effective preventive
Hansen’s disease Loss of sweating and hair growth Lepromin Test – determines susceptibility to leprosy measure against leprosy
Thickened and painful nerves Good personal hygiene
-an ancient disease Muscle weakness or paralysis or Treatment: Adequate nutrition
and is a leading cause extremities Ambulatory chemotherapy through use of MDT Health education
of permanent physical Pin and redness of the eyes Domiciliary treatment as embodied in RA 4073 which
disability among the Nasal obstruction or bleeding advocates home treatment
communicable Ulcers that do not heal
diseases PAUCIBACILLARY (tuberculoid and indeterminate);
Late Signs: noninfectious type
Madarosis Duration of treatment: 6 to 9 months
Loss of eyebrows Procedure:
Inability to close eyelids Supervised: Rifampicin and Dapsone once a month on the
(lagophthalmos) health center supervised by the rural health midwife
Clawing of fingers and toes Self-administered: Dapsone everyday at the client’s house
Contractures
Chronic ulcers MULTIBACILLARY (lepromatous and borderline); infectious
Sinking of the nosebridge type
Enlargement of the breast Duration of treatment: 24-30 months
(gynecomastia) 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
17 Communicable Disease Nursing

2. Anthrax Bacillus anthracis Contact with 1. Cutaneous form – most common Treatment: Penicillin Proper handwahing
a. tissues of animals - itchiness on exposed part
Other names: (cattle, sheep, goats, - papule on inoculation site Immunize with cell-free
Malignant pustule horses, pigs, etc.) dying - papule to vesicle to eschar vaccine prepared from culture
Malignant edema Incubation period: of the disease - painless lesion filtrate containing the
Woolsorter disease few hours to 7 days most b. biting flies that had protection antigen
Ragpicker disease cases occur within 48 hours partially fed on such 2. Pulmonary form – contracted from
Charbon of exposure animals inhalation of B. anthracis spores Control dust and proper
c. contaminated hair, - at onset, resembles common URTI ventilation
wool, hides or products - after 3-5 days, symptoms become
made from them e.g. acute, with fever, shock, and death
drums and brushes
d. soil associated with 3. Gastrointestinal anthrax –
infected animals or contracted from ingestion of meat from
contaminated bone meal infected animal
used in gardening - violent gastroenteritis
- vomiting
- bloody stools

3. Scabies Sarcoptes scabiei Direct contact with Itching Diagnosis: Personal hygiene
- An itch mite infected individuals Appearance of the lesion Avoid playing with dogs
parasite When secondarily infected: Intense itching Laundry all clothes and iron
Incubation Period: Skin feels hot and burning Finding of causative mite Maintain the house clean
24 hours Environmental sanitation
When large and severe: fever, headache, Treatment: (limited entirely to the skin) Eat the right kind of food
and malaise Examine the whole family before undertaking treatment Regular changing of clean
Benzyl benzoate emulsion (Burroughs, Welcome) – cleaner to clothing, beddings and towels
use and has more rapid effect
Kwell ointment

4. Pediculosis Pediculosis Direct contact Itchiness of the scalp Kwell shampoo (twice a week) Proper hygiene
Capitis (head lice)
Other name: Corporis (body lice) Common in school age One tbsp water + one tbsp vinegar
Phthipiasis Pubis (crab lice)

VIII. INTESTINAL PARASITISM


18 Communicable Disease Nursing

MODE OF
DISEASE CAUSATIVE AGENT PATHOGNOMONIC SIGN MANAGEMENT/TREATMENT PREVENTION
TRANSMISSION
1. Ascariasis Ascaris lumbricoides Fecal-oral route Pot-bellied Diagnostic Test: Fecalysis Proper handwahing
Voracious eater
Other names: (nematode) 5 Fs: Finger, Foods, Feces, Thin extremities Treatment:
Roundworm Flies, Fomites Antihelminthic: Mebendazole / Pyrantel Pamoate
Giant worms
2. Taeniasis Taenia solium – pork Eating inadequately cooked Muscle soreness Diagnostic Test: Fecalysis Proper handwahing
Taenia saginata – beef pork or beef Scleral hemorrhage
Other name: Dyphyllobotruim latum – fish Treatment: Cook pork and beef adequately
Tape worm 5 Fs: Finger, Foods, Feces, Antihelminthic: Mebendazole / Pyrantel Pamoate
Flies, Fomites

3. Capillariasis Trichuris trichuria Eating inadequately cooked Abdominal pain Diagnostic Test: Fecalysis Proper handwahing
seafood Diarrhea
Other name: Capillararia Philippinensis borborygmi Treatment: Cook seafoods adequately
Whip worm 5 Fs: Finger, Foods, Feces, Antihelminthic: Mebendazole / Pyrantel pamoate
Flies, Fomites
4. Enterobiasis Enterobium vermicularis Inhalation of ova Nocturnal anal itchiness Diagnostic Test: Fecalysis / tape test Proper handwahing
Toilet seat
Other name: Infected bedsheets Treatment: Proper disinfection of beddings
Pinworm Antihelminthic: Mebendazole / Pyrantel pamoate
5 Fs: Finger, Foods, Feces,
Flies, Fomites
5. Ancyloclos- Ancyclostoma duodenal Walking barefooted Dermatitis Diagnostic Test: Fecalysis Proper handwahing
tomiasis
Necatur americanus 5 Fs: Finger, Foods, Feces, Anemia Treatment: Avoid walking barefooted
Other name: Flies, Fomites Antihelminthic: Mebendazole / Pyrantel pamoate
Hookworm Black fishy stool
ROBERT C. REÑA, BSN

IX. OTHER COMMUNICABLE DISEASES

MODE OF
DISEASE CAUSATIVE AGENT PATHOGNOMONIC SIGN MANAGEMENT/TREATMENT PREVENTION
TRANSMISSION
1. Pneumonia Bacteria: Droplet Rusty sputum Diagnosis: Avoid mode of transmission
Pneumococcus, streptococcus Fever and chills Based on signs and symptoms
Types: pneumoniae, staphylococcus Incubation Period: Chest pain Dull percussion on affected lung Build resistance
a. Community aureus, Klebsiella pneumonia 2 – 3 days Chest indrawing Sputum examination – confirmatory
Acquired Pneumonia (Friedlander’s bacilli) Rhinitis/common cold Chest x-ray Turn to sides
(CAP) Productive cough
b. Hospital / Virus: Fast respiration Management: Proper care of influenza cases
Nosocomial Haemophilus influenzae Vomiting at times Bedrest
c. Atypical Convulsions may occur Adequate salt, fluid, calorie, and vitamin intake
Fungi: Pneumonocystis carinii Flushed face Tepid sponge bath for fever
pneumonia Dilated pupils Frequent turning from side to side
19 Communicable Disease Nursing

Highly colored urine with Antibiotics based on CARI of the DOH


reduced chlorides and increased
urates Oxygen inhalation
Suctioning
Expectorants / mucolytics
Bronchodilators
Oral/IV fluids
CPT
2. Mumps Mumps virus, a member of Direct contact Painful swelling in front of the Supportive and symptomatic MMR vaccine
family Paramyxoviridae ear, angle of the jaws and down
Other name: Source of infection: the neck Sedatives – to relieve pain from orchitis Isolate mumps cases
Epidemic Parotitis Secretions of mouth and nose Fever Cortisone – for inflammation
Malaise
Incubation Period: Loss of appetite Diet: Soft or liquid as tolerated
12 to 26 days, usually 18 days Swelling of one or both testicles
(orchitis) in some boys Support the scrotum to avoid orchitis, edema, and atrophy

Dark glasses for photophobia


3. Influenza Influenza virus Direct contact Sudden onset Supportive and symptomatic Avoid use of common towels,
A – most common Droplet infection or by Fever with chills glasses, and eating utensils
Other name: B – less severe articles freshly soiled with Headache Keep patient warm and free from drafts Cover mouth and nose during
La Grippe C – rare nasopharyngeal discharges Myalgia / arthralgia TSB for fever cough and sneeze
Airborne Boil soiled clothing for 30 minutes before laundering
Period of Communicability:
Probably limited to 3 days from Incubation Period:
clinical onset Short, usually 24 – 72 hours
4. Streptococcal sore Group A beta hemolytic Droplet Sudden onset Diagnosis: Avoid mode of transmission
throat streptococcus High grade fever with chills Throat swab and culture
Complication: Enlarged and tender cervical
Other name: Other diseases: Rheumatic Heart Disease lymph nodes Treatment: erythromycin
Pharyngitis Scarlet fever Inflamed tonsils with
Tonsillitis St. Anthony fire mucopurulent exudates Care:
Puerperal sepsis Headache Bed rest
Imoetigo dysphagia Oral hygiene with oral antiseptic or with saline gargle (1 glass
Acute glumerulonephritis of warm water + 1 tsp rock salt)
Rheumatic Heart Disease Ice collar
5. Meningitis Meningococcus Direct (Droplet) A. Sudden Onset Diagnostic Test: Respiratory Isolation
Neisseria meningitides - high fever accompanied by
Other name: Incubation Period: chills Lumbar puncture or Lumbar tap - reveals CSF WBC and
Cerebrospinal fever 2 - 10 days - sore throat, headache, protein, low glucose; contraindicated for increased ICP for
prostration (collapse) danger of cranial herniation

B. entrance into the bloodstream Hemoculture – to rule out meningococcemia


leading to septicemia
(meningococcemia) Treatment:
a. rash, petchiae, purpura Osmotic diuretic (Mannitol) – to reduce ICP and relieve
cerebral edema; Alert: fastdrip to prevent crystallization
20 Communicable Disease Nursing

C. Symptoms of menigeal Anti-inflammatory (Dexamethasone) – to relieve cerebral


irritation edema
- nuchal rigidity (stiff neck) – Antimicrobial (Penicillin)
earliest sign Anticonvulsany (Diazepam / Valium)
- Kernig’s sign – when knees
are flexed, it cannot be extended
- Brudzinski signs – pain on Complications:
neck flexion with automatoc Hydrocephalus
flexion of the knees Deafness (Refer the child for audiology testing) and mutism
- convulsion Blindness
- poker soine (poker face / flat
affect)
- Increased ICP
(Cushing’s triad: hypertension,
bradycardia, bradypnea) and
widening pulse pressure

IX. KILLER DISEASES OF THE NEW MILLENNIUM

MODE OF
DISEASE CAUSATIVE AGENT PATHOGNOMONIC SIGN MANAGEMENT/TREATMENT PREVENTION
TRANSMISSION
1. Meningococcemia Neisseria meningitides Direct contact with High grade fever in the first Respiratory isolation within 24 hours Universal precaution
respiratory droplet from 24 hours Chemoprophylaxis
nose and throat of infected Hemorrhagic rash – Drug-of-Choice: Penicillin Proper hand washing
individuals petechiae
nuchal rigidity
Incubation Period: Kernig’s sign
2 – 10 days Brudzinski sign
Shock
Death
2. Severe Acute Coronavirus Close contact with Prodromal Phase: No specific treatment Utilize personal protective
Respiratory Syndrome respiratory droplet Fever (>38 0C) equipment (N95 mask)
/ SARS secretion from patient Chills PREVENTIVE MEASURES and CONTROL
Malaise 1. Establishment of triage Handwashing
Earliest case: Incubation Period: Myalgia 2. Identification of patient
Guangdong Province, 2 – 10 days Headache 3. Isolation of suspected probable case Universal Precaution
China in November Infectivity is none to low 4. Tracing and monitoring of close contact The patient wears mask
2002 5. Barrier nursing technique for suspected and Isolation
Respiratory Phase: probable case
Global outbreak: March Within 2-7 days, dry
12, 2003 nonproductive cough
progressing to respiratory
First case in the distress
Philippines:
April 11, 2003
21 Communicable Disease Nursing

3. Bird Flu Influenza Virus H5N1 Contact with infected birds Fever Control in birds: Isolation technique
Body weakness and body 1. Rapid destruction (culling or stamping out of all Vaccination
Other Name: Incubation Period: malaise infected or exposed birds) proper disposal of carcasses Proper cooking of poultry
Avian Flu 3 days, ranges from 2 – 4 Cough and quarantining and rigorous disinfection of farms
days Sore throat 2. Restriction of movement of live poultry
Dyspnea
Sore eyes In humans:
1. Influenza vaccination
2. Avoid contact with poultry animals or migratory
birds
4. Influenza A (H1N1) Influenza Virus A H1N1 Exposure to droplets from - similar to the symptoms of Diagnostic: - Cover your nose and mouth
the cough and sneeze of regular flu such as Nasopharyngeal (throat) swab when coughing and sneezing
Other Name: This new virus was first the infected person Fever Immunofluorescent antibody testing – to distinguish - Always wash hands with
Swine Flu detected in people in Headache influenza A and B soap and water
April 2009 in the United Influenza A (H1N1) is not Fatigue - Use alcohol- based hand
May 21, 2009 – first States. transmitted by eating Lack of appetite sanitizers
confirmed case in the thoroughly cooked pork. Runny nose Treatment: - Avoid close contact with
Philippines Influenza A (H1N1) is Sore throat Antiviral medications may reduce the severity and sick people
fatal to humans The virus is killed by duration of symptoms in some cases: - Increase your body's
Cough
June 11, 2009 - The cooking temperatures of Oseltamivir (Tamiflu) resistance
- Vomiting or nausea
WHO raises its 160 F/70 C. or zanamivir - Have at least 8 hours of
- Diarrhea
Pandemic Alert Level to sleep
Phase 6, citing Incubation Period: - Be physically active
significant transmission 7 to 10 days - Manage your stress
of the virus. - Drink plenty of fluids
- Eat nutritious food

ROBERT C. REÑA, BSN