UNI

T1:BASI
CPRI
NCI
PLESofMI
CROBI
OLOGYandPARASI
TOLOGY:EPI
DEMI
OLOGYandt
he
NURSE

ENGAGE
Nurses play an i
mpor tantrol
ei nthe fi
eld of
Epi
demiologybecauseoft heirbackground i
n nursing sci
enceaswel lasskill
sforworking i
nthe
community.Beingknowledgeablewithepidemiol
ogicalconceptsandprinci
pleswil
lbri
ngaboutabetter
under
standingofthei
rrol
esrelatedt
oi nf
ecti
ousdiseasecausation,
prev
ent i
onandcontrol

Asfuturenurses,
studyi
ngtheori
ginandcausesofdiseasesinthecommunit
ywouldident
if
ythe
causeoftheoutbreakandwilll
eadtoint
ervent
ionstoprev
entfurthercasesoft
hedi
seasethusyouwil
l
beablet
opr ot
ectpeoplether
efor
esavi
ngmoneyt hr
oughprev
enti
on.

Whati
syourexperienceofaninfecti
ousdiseaseandwhatdoweknowaboutt hem?
“
Irecal
lthatwhenIwasi nGrade4,myt eachersai
dtooneofmyclassmatest
hatshehastogo
homebecauseshehassor eey es,andthatshemustst ayhomeforatl
eastoneweeksothatshei
snot
goi
ngtoinf
ectherclassmates.
”-Anony mous

Fr
om theaboveexperi
ence,thestudentpresent
ssor eeyesasaninf
ect
iousdiseaset
hatcan
spr
ead.Topreventotherst
udent
st ogetinfect
ed,thestudentwasadvi
sednott
oattendschoolf
orat
l
east1week.So,whatisaninf
ecti
ousdisease?

I
nfecti
ousDi seasesarediseasescausedbymi crobest hatspread.Thereasonwhyy oumaybe
absentformor et
hanonedayi sbecausey ouhav eani nf
ectiousdiseasewhichhast hecapabi
l
ityof
i
nfecti
ngot hers.Whet herornotaninfecti
ousdiseaseoccursdependsonmanyf actor
s,incl
udi
ngthose
pert
aini
ngtot hepathogen,thosepertai
ningtot
hehost ,
andt hosepertaini
ngtot
heenv i
ronment.

Now,
howdoy
ougetani
nfect
iousdi
sease?Thef
oll
owi
ngpar
toft
heuni
twi
llhel
pyouont
his.

EXPLORE
Letusexpl
oremor
eaboutthehow oneget ssi
ckofani nf
ecti
ous
di
sease.Wecanuti
li
zet
heEpi
demi
ologi
calTr
iadort
heEpi
demi
ologi
cTriangl
e

whichi samodelt
hat
scienti
sts have
dev el
oped f
or
studying heal
th
problems.

The Epi
demi
ologi
c
Tri
ad

The
Epi
demi
ologi
calTr
iad
or Epidemiol
ogi
cal
Trianglereferst
ot heTradi
ti
onalModelofDiseasecausati
on.Si
nceiti
satri
adorat
ri
angl
e,iti
mpliesthat
therear ethreefactor
sinvol
vedwhent her
ei sadisease.Thesethr
eefact
orsar
etheext
ernalagent,the
env i
ronmentandt hesuscepti
blehost

TheTr
ianglehast hreecor ners(call
edv ert
ices):
 Agent ,ormi crobet hatcausest hedisease(the“what
”oftheTri
angle)
 Host ,oror ganism harboringthedisease( t
he“who”oftheTri
angle)
 Env ir
onment ,orthoseext ernalfactorsthatcauseorall
owdiseasetransmi
ssi
on(
the“
wher
e”of
theTriangle)

Ther ol
eoft henursei sto br
eakat
l
eastoneoft hesidesoftheTriangle,
di
srupti
ngtheconnecti
onbetweent he
envi
ronment,thehost,andtheagent ,
and stopping the conti
nuati
on of
di
sease.

ComponentsoftheEpidemiol
ogi
cTri
ad
The AGENT i
s a har
mfulmi
croor
gani
sm thatis presentinthe ENVI
RONMENT t
hatat
tacks a
SUSCEPTI
BLEHOST.

TheAGENT( What )isr eferredt oani nfect i

ousmi croorgani sm orapat hogenwhi ch
may bea:v ir
us,bact eri
um,par asite,orot hermi crobe.Gener all
y,theagentmustbe
presentf ordi seaset ooccur ;howev er,pr esenceoft hatagental onei snotal ways
sufficientt ocausedi sease.Av ari
etyoff actorsi nfluencewhet herexposur et oan
organi sm wi llresultindi sease,i ncludingt heor ganism’ sabi litytocausedi sease,and
doseorhowmany .
Bacteri
a:Bact eriaar esi ngle-cell
edor ganismst hatr eproduceby
themsel ves.Theyar elargert hanv ir
uses( butst il
lmucht oosmal ltobe
seenwi tht henakedey e) .Theyar efil
ledwi thf l
uidandmayhav ethreadl ike
structurestomov et hemsel ves,likeat ail.
Vir
us:Av i
rusmayhav easpi nyout sidel ayer,calledt heenv el
ope.
Viruseshav eacor eofgenet icmat eri
al,butnowayt or eproducei tont heir
own.Vi rusesinfectcel lsandt akeov ertheirrepr oduct i
vemachi neryt or eproduce.
Fungi:Fungiar el ikepl ant smadeupofmanycel l
s.Theyar enotcal led
plantsbecauset heycannotpr oducet heirownf oodf rom soi landwat er.Instead,
theyliveoffanimal s, i
ncludi ngpeopl e,andpl ants.Mushr oomsandy eastar ef ungi .
Pr otozoa:Pr ot ozoa arev ery small.
Mostl iv
ei nwat er.Theyar epar asi
tes,which
meanst heyl iveof fot herorganisms,i nsome
caseshumans.Mal ar i
ai scausedbyapar asi
ti
c
prot
ozoan.

The HOST ( Who) car ri

es t he di sease.
Host  
referstot hehumanwhocangett hedi sease.Avari
etyoffactorsintri
nsictothehost ,somet imes
call
edr iskfactors,
caninfluenceani ndiv
idual’
sexposur
e,suscepti
bil
ity,orresponsetoacausat iveagent.
Oppor tunit
iesforexposurear eofteninfl
uencedbybehav i
orssuchassexualpr act
ices,hy
giene, andot her
personalchoi cesaswel lasbyageandsex.Suscept i
bil
i
tyandr esponset oanagentar einf l
uencedby
factorssuchasgenet i
ccomposi t
ion,nutr
it
ionalandimmunologicstatus,anatomicstruct
ure, presenceof
diseaseormedi cati
ons,andpsy chologi
calmakeup.
The ENVI RONMENT ( Wher e)br i
ngs the agentand host
together
.Env i
ronment 
referstoextrinsi
cfactorsthataffect
theagentandt heopportunit
yforexposur e.Envi
ronment al
factorsi
ncludephysi
calfactorssuchasgeol ogyandcl i
mat e,
biol
ogicfactorssuchasinsectsthatt r
ansmittheagent,and
socioeconomi cfact
orssuchascr owding,sanit
ation,andt heavail
abil
i
tyofhealt
hservi
ces.Thusa
poll
utedenv i
ronmentwouldmeant hattherearealotofhar mful
microbesthatar
epr
esent
.

Ourhomeal
soi
sasour
ceofagent
s.Thear
ti
clebel
owpr
esent
sfact
sthatt
her
ear
emi
crobesi
n
ourhome.

HowaboutourHomeEnv i
ronment
?Ar
eMi
crobesi
nourhomesFr
iendsorFoe?
Yell
aHewi ngs-
Mar t
in,Ph.
D. 
onOctober13,
2017
Factschecked by
 JasminColl
ier
Publi
shedinMedi calNewsToday

Theamountofmi cr
obest hatshareourl
i
ving
spacesmightcomeasasur pri
set omany .Butthe
keyquesti
onis,ar
etheybadf orourhealt
h?Bact
eria,
vi
ruses,
fungi
,andparasi
tesallli
vearoundourhomes.

When i tcomes t o microorgani

sms i n our
l
ivi
ng env i
ronments, we ar e bombar ded wi th
anti
bact
eri
alandant i
vi
ralsoaps,cleani
ngpr oductsof
ever
ydescri
ption,andagener alnotionthatwemust
keepourhousescleantocombatdeadl ymi crobi
althr
eat
s.

Ont heotherhand,wear ef requent

lyr
emindedthatprobi
oti
cmicrobeshavesigni
fi
canthealt
h
benefi
ts.
Microor
ganismsar eever-
presentinourenvi
ronmentandinourbodies,andmanyareknownt o
bebeneficial—orev enessent
ial—f orourheal
th.However,somearepathogensandcanmakeusv er
y
si
ck,andt heycansomet i
mesev enkil
l us.

Keentoknowwhatmi cr
obesmightbei
nhabi
ti
ngthevar
iouspart
sofmyhome,Idel
vedint
othe
scient
if
icli
ter
atur
eandf oundoutwhysomeofourmi cr
oscopi
cr oommatesar
egoodforus,andwhy
othersposeasigni
fi
cantthr
eatt
oourheal
th.

Whatmi cr
obesl urkaroundourhomes?
Scienti
stsf r
om NSFI nternati
onal— whi chisbasedinAnnAr bor,MI—  tested 22householdsin
SoutheastMi chigan. They f ound t hatdishwashing sponges contained the hi ghestnumberof
microorganisms,f oll
owedbyt oothbrushhol ders,petbowls,ki
tchensi nks,
 coffee 
reservoir
s,ki
tchen
countert
ops,st oveknobs,pett oys,andt oi
letseats.Inthestudy,theaut hor
sf oundy eastandmol ds,
bacteri
ai nthecol if
ormf amil
y( i
ncludi Escher
ng  i
chi
acoli) St
,and  aphylococcusaur eus onmanyoft he
surf
acest ested.
Toassesst hemi cr
obialdiver
sityi
nhousedust ,ateam ofscienti
sts—whi chwasl edbyJordan
Pecci
a,aprofessorofchemi calandenv ironmentalengineeringatYal eUniver
sit
yinNew Hav en,CT
— t
ested 
samplesfrom 198homesi nConnect i
cutandMassachuset t
s.Ther esear
chersfoundt hatthe
mostcommonf ungalspeci
eswere Leptosphaeruli
nachartarum, Epi
coccum nigr
um,and Wallemiasebi.
Themostabundantbacteri
awer ef
rom the Staphyl
ococcus,St
  reptococcus,
and Cory
nebact
eria f
ami l
i
es.

Homeswi t
hpetsandt hoselocatedinsuburbanareashadmor ediversebacteri
alspecies,whil
e
thosewithreportedwaterleaksharboredmor efungi.
Meanwhi l
e,scienti
stsf r
om SeoulNat i
onalUniversi
tyin Korea 
studi
ed 
the bacter
iat hatinhabitour
refr
iger
atorsandt oi
letseats.Theyf oundthatthemanyoft hebacter
iapresentwer ealsoresidenton
humanski n,i
ndicati
ngthatwearethesour ceofalotofthemicrobesinourli
vi
ngenv i
ronment.

“Inthi
sstudy
,mostbacteri
adet
ectedwer epr
obablynotpat hogensoropport
unist
icpat
hogens,and
generabel
ongingt
ocommonpathogenswer edetect
edinonlyav erysmal
lfr
acti
onofcommuni t
ieson
thesurf
acesofref
ri
ger
ator
sandtoi
let
s,”t
heauthorsexpl
ain.

So,ourti
nyroommatesareeverywhere:fr
om ourki
tchensinkstoourli
vi
ngroom fl
oor
sand
toot
hbrushholder
s.Theykeyquest
ionthatremainsiswhatthei
rimpactonourheal
this.Theanswer
dependsonourage,t hest
ateofourimmunesy st
em,and,ofcourse,t
heindi
vi
dualmicr
oor
gani
sm in
questi
on.

Allergyandhy gi
ene
Accordingtot he“hygienehy pothesis”— whi chwas
original
ly 
proposed byProf.Dav i
dSt rachani n1989— al l
ergic
diseases ar e ablet o be prevented “ by infecti
on in early
childhood,t r
ansmitt
ed by unhy gienic cont act wi
th ol der
si
bl i
ngs,oracqui r
ed prenatal
lyf rom a mot herinf
ected by
cont actwithherol derchil
dren.” Housedustexposesust o
diversemi crobes.

Inan art
icle 
publishedintheOct oberedit
ionofNat
  ure
Immunol ogy,Profs.Bar tN.Lambr echtandHami daHammad— f r
om theVI BCent
erforInfl
ammat i
on
ResearchatGhentUni ver
sityinBel gi
um — explainthatstudiesinanimalmodelshav eshownt hat
exposuretosomev i
ruses,bacteri
a,andparasit
esisli
nkedtolowerratesofall
ergy
.
All
ergi
cdi seases,includi
ng eczema, hayfever,
 
asthma,and f
oodal l
ergi
es,aff
ect 
50mil
l
ion 
indiv
idual
sin
theUnitedStates,whi l
ehayf everal
oneaf f
ects 
400mi l
li
on 
indi
vidual
sgloball
y.

Al l
ergiesdev elopwhenourbodi esmi st
akeanot herwisehar mlesssubst anceasat hreatand
reactwi thani mmuner esponse.Mi crobesar eknownt oaf fectthi
spr ocessi nsev eralway s.Cer t
ain
bacteria, such as  Bacteri
oides,Bi
  fi
dobacteri
um, Faecal
  i
bacter
ium,  
and Enter
obact eri
a, pr oduce
met abolitest hatpromot ethegener ati
onofr egulatoryTcel l
s.Thesecel lsplayamaj orroleinpr otecting
usf rom dev elopingallergies,butchildr
enwhoar epr onet oallergyareknownt ohav elowerl evelsoft hese
typesofbact eriaintheirgut s.
Mi crobialcomponent sal soaffectanot hertypeofi mmunecel l.Dendriti
ccellspat r
olepi theli
albar ri
ers
— namel y,theski n,gut ,andl ungs— wher etheydet ectincomi ngallergens.Andi ft hi
shappensi nt he
absenceofmi crobialcomponent s,dendr it
iccellst endt odr iveall
ergicimmuner eactions,wher easi f
mi crobesar epr esent, t
heydonot .
So, wher ecanwef i
ndt hesebenef ici
almi cr
oorganismst hatmi ghtprotectusf rom developingal lergies?

Micr
obest hatmightgiveust heedge
Prof.Peccia 
found t
hatcer t
ainbenefici
albacteriawerepref
erenti
all
yf oundi
nhomest hathoused
mult
ipl
ef ami l
iesandthosewi thmor ethanthreechildren.
Oneoft hese,Faecal
  i
bacteri
um pr ausni
tzi
i,“i
santi-
infl
ammat or
yandpr ot
ecti
v eagai
nst 
Crohn’
sdisease,”
heexplains.Member soft helactobacil
lusfamilywer ealsofoundinhighernumber sinsuchhouseholds,
andthesepr obiot
icbacteri
ahav ebeeni mpli
catedinpr otect
ionagai
nstall
ergiesandasthma.
 Inasepar ate study,
Prof.Peccia’
st eam foundthatyeast
sint
hef ungalcl
ass Kondoa 
mayhav
ea
protect
iveeffectagainstsev er
east hmawhenpr esenti
nt hehome.Drinkingunpasteur
izedcow’
smil
kis
l
inkedtoal owerr i
skofal ler
gy.
Exposuret omi croorganismsi n r
aw mi l
k andthosei nthedustofhomesl ocatedonf armshasbeen
strongl
yimpl i
catedinl owerall
ergyrates.
Howev er,bact eri
a and f ungi aren’tthe onl yf ri
endly
microorganisms.

Although most peopl et end not t o associ ate

parasites wi t
h West er
n nations,i nt he U.S.,
 
mill
ions of
i
ndividual s ar e chr onical
ly i nfected wi th t hese
microor ganisms.
Buti t’
s notal lbad news:t herei s ev i
dence thatt iny
parasiticwor mscal l
edhel minthspr otecttheirhostf rom
all
ergies.
Manyal ler
gensaresimilarinstructuretohel mint
hproteins,
whichi swhyi ncasesofchr onicexposur et ohelminths,
thesepr oteinscompetewithallergens,leadi
ngt onon-al
lergi
cimmuner
esponses.

Notal
linf
ecti
onsarebenef
ici
al.Forexampl
e,l
owerr
espi
rat
oryt
racti
nfect
ionsi
nchi
l
drenunder3
y
ear
sofageareariskfact
orf
orwheezingandasthma.

Thehy gienehy pothesishasbeencr i

ti
cizedinlightoft his.Prof.Lambrechtsay st hatnew
theori
essuggestt hatlossofdi versi
tyinthehumanmi crobiome— at opicIrecentl
yexpl oredi
na
separate art
icl
e — meanst hatt hemi cr
obesandpar asi
test hatoncepr ovideduswi t
hpr otecti
onfrom
all
ergi
esnol ongerfulf
il
lthi
sf unct
ion.
Whilemi croorganismsmaypl ayani mport
antrol
ei npr
eventingal
lergicdi
seasefrom developinginsmall
chil
dren,theycanposeaser i
ousthreattotheheal
thofothers.

Whenaremi crobesbadf orourheal

th?
Forpeoplewhohav ealr
eadydevelopedall
ergicdi
sease,mi
crobesinthelivi
ngenvi
ronmentspell
badnews. Ear l
ylif
efungali nf
ecti
ons,especi
all
yt hoseoftheairways,ar
e l
inked 
tothewor seni
ngof
exi
sti
ngaller
gicasthma.I nf
ecti
onsoft heairwayswi thvi
rusesandbacteri
acanhav esimi l
areffect
s,
whil
efungalskini
nfect
ionsareknownt otri
ggereczema.

Prof.Peccia al
so f
ound t
hatthe homes ofsev erel
yast hmati
c chil
dren tended to har borsimilar
microbialal
ler
gens.Inparti
cul
ar,highconcentrationsoff ungiweref oundi nthehomesoft hese
chil
dren,wit
hyeastsinf
ungalcl
ass Vol
utel
la 
standingout.
Our refri
gerat
ors are i deal l
iving
envir
onmentsf orharmfulmicr
oor ganisms.I n
addit
iontothedangert hatmicr obesposet o
those alr
eady aller
gic orast hmat ic,food-
bornehousehol dmi cr
oorgani
smscont r
ibute
to a si
gnifi
cantnumber s ofillnesses each
year.

TheCent ersf orDi seaseCont roland

Prevention ( CDC) 
estimat e that everyy ear,
3,000peopl edief r
om  f
oodpoi soni
ng.Her e,
thecul pri
tsinclude Salmonel la,cert
aintypes
of E.coli
,Li
  ster
ia,
andf ungi
.

Accor
ding tot he 2013 NSF Int
ernati
onal
Househol
d Ger m Study, the ref
rigerat
or veget
able compartment was a r eady sour ce
of
 Sal
monell
a,Li
  st
eri
a,andfungi
,whi
le E.col
i 
wer
efoundint
herefr
iger
atormeatcompartment,aswell
asonr
ubberspat
ulas,
blendergasket
s,canopener
s,andpi
zzacut
ter
s.

So,thebot tom li
nei st
hatamongt heplet
hor aofmi croor
ganismst hatinhabi
tourhomesand
l
ivi
ngspaces,somear efr
iendsandsomearefoes.Mor eimportantl
y,howwer eacttoparti
cul
armicrobes
dependsonouri ndi
vidualimmunesystems.
Doest hatmeant hatIshoul
dkeepmyhomemet i
cul
ouslyclean?Cleaningmykitchen’
shotspots
—most l
ythedi shwashingsponge,r
efri
ger
ator
,ki
tchensink,counter,andcookingutensi
ls—wi l
lcer
tainl
y
gosomewayt owardpr ot
ecti
ngmyf amil
yfr
om contracti
ngfoodpoi soni
ng.

Asfortherestofthemicr
obes,itdepends.Inhomeswi thfamilymemberswhoal
readyhave
all
ergi
es,reduci
ngexposuretoanyoft heculpri
tsthattr
iggersymptomsmakessense. Butarewe
i
ncreasingl
ybecomingtrappedi
nav i
ciouscycleofcleanl
inesst
opr evental
ler
gysy
mptoms,depr
ivi
ng
thenextgenerat
ionfr
om themuch-
neededearlyexposuretomicrobes?

Therei
snoclearanswer,butscient
ist
sar eget
ti
ngclosert
ofi
ndi
ngouthow exposur
eto
mi
croor
gani
smsmi
ghthavepr
otect
edusfrom all
ergi
esi
nthepast
.

“I
nthefutur
e,wemi ghtalsoseeeff
ecti
veandl
arge-
scaleprevent
ivestr
ategi
esbasedont
hisnew
knowl
edget hatcan rest
oret helostsymbioti
crel
ati
onshipsbetween mi cr
oorgani
smsand humans
wit
houtcausi
ngdiseaseorrequir
ingaret
urntoanunhygi
enicli
fest
yle.
”

From thisar
ti
cle,
wecanconcl udet
hatmicr
obesarepresenti
nourhome
envi
ronment. Ourheal t
hpracti
cesareimpor
tantwhetherornotthese
microorgani
smswi l
lremainasourf
ri
endsorasourenemies.

EXPLAI
N
HowI st
heEpi
demi
ologi
calTr
iad
Appl
ied?

Thei nt
eract
ionsofthehost
,agent,and
envi
ronmentcorr
elat
ewitht
hespr
eadofi
nfecti
ous
di
seases

Theepidemiologicaltri
adi sdesi gnedtobeshapedl i
kea
teet
ertot
ter(seesaw)wi t
ht heenv ir
onmentbeingthebase,
thehostbei
ngononesi deandt heagentbeingont heother
.
When the teetert ott
eri s bal
anced i tis known as the
equil
i
bri
um st ate,t hi
s state signif
ies t
hatev er
ythi
ng is
heal
thy.

Inascenar
iowherethereisaninf
ecti
ousdisease,t
heteet
er
tot
terwoul
dbewei ghtedtowardsoneside.Thegoalofan
epi
demiol
ogisti
stodeciphert
heconnecti
onbet weenanyof
t
heset
hreemai
nfact
ors

Imbal ancetowar dstheAgent

Whenl ookingatt heepi demiologicalteetertot
ter,t
herear emoment swhent hereisani mbalance
thatcausesmanydi f
ferentscenar i
os.Iftheimbal anceistowar dstheagentitisconsi deredast heagent
hav ingmor eofanabi l
ityt ocauseadi seaseonman.Thi scanbeshownbyt hecor onav ir
us,ast hi
s
diseasei sincreasi
ngi ncasesev er
yday .Inthissituat
ion,t
hev irusesaretheagent scar r
y i
ngt hecorona
virusandi nfecti
ngt hehost ,humans.Thecor onav ir
ushav eal somorecont rolofpassi ngt hedisease
becauseoft hei
rinvisi
bili
tyandmodeoft r
ansmi ssi
on.Al so,thereisnoabi l
i
tyt ot el
lt hediff
erence
bet weenacommonf l
uv iruswi ththecor onav ir
us.Thisallowst hehosttot r
ansmi tthedi seasetoother
host swi t
houtev enknowi ng.Ev entuall
y ,thi
sexpandedt hear eat hediseaseinfectedbecauseoft he
agent ’
sabili
tytotransmi tthediseaset ot hehost.

ImbalanceTowar dst heHost

Anotherout comet hati sshowni nt hei mbal anceoftheepi demi ologi calt eetertot
terist owar ds
thehost .Thisimbalanceexpl ainsthattheamountofway saper soni ssuscept i
blet oadi seasei ncreased.
Agoodexampl eoft hiscanbeshownbyt heH1N1f luvir
us.Thef luv i
rusi st ransmi ttedfrom per sont o
persont hroughcont actwi thot herswhohav et hefluorpossiblythroughsur facest hatpeopl ewi t
ht hef l
u
havet ouchedi nthepast .Ev eryyear,peoplegeti nfectedwi t
hthef luv i
rusev eni ft heyhavehadi tint he
pastorhav etakenf luv accines.Thi sisbecauset heH1N1f l
uv ir
usi sanRNAv ir
us,whi chmeanst hatit
mut atesandchangesev er
ysoof ten.Thisf orcesdoct orstochanget hef l
uv accineev er
yy eart otryand
decreaseoursuscept ibil
ity
.Unf or
tunatel
y,there’sapossi bil
it
ythatt hevacci nemaynotwor kandcanst i
ll
causey out ocont r
actt hev irus.This,ult
imat el
y ,
leavespeoplev ulnerabl
et ot hedi seasewhet hertheyar e
vaccinatedornot .Thi sshowshowahost ’ssuscept ibil
it
ytoadi seasemayi ncr easebecauseoft heagent
andenv ironmentt hey ’
r ein.

ImbalanceTowar dstheEnv ironment

Theenv i
ronmental sopl ay sakeyr oleinhowt heagentandhostar eaffectedbyadi sease.The
envir
onmentpl aysar ol
ei nwher et hediseasei smostl i
kelyt ospr
eadandwher ei ti
scur rent l
ylocated.
Withtheuseofpr evi
ouslyexpl aineddi seases,t hecoronav ir
usisonl yfoundi nmostpl aceswi t
hahot
cli
matesuchast heUni tedStates, Europe, UnitedKingdom, AsiaPacif
ic.Althought hefl
ui sadi seaset hat
i
s common wor l
dwide,i tist ypical
lyt ransmi tt
ed int he col
dermont hs oft he year.Thi s shows
epidemiol
ogist
st hatmor eprev ent i
onshoul dbepl acedont heseareaswhent hecl i
mat ecor relat
eswi th
therateofsuscept i
bil
it
ytot hehost .Incer tai
ntimesoft hey ear
,inspecificenvironment s,thehostmay
nothaveahi ghsuscept i
bil
it
yt ocer tai
ndi seases, butmaybesuscept ibletoothers.Justl i
ket hehostand
theagent,t
heenv ir
onmenthasdi rectcorrelati
ont otheotherfact
orswhenspr eadingadi sease.
 Theroleoft
henurseistobreakatleastoneofthesi
desoftheTriangle,
di
srupti
ngtheconnecti
onbetweent heenv i
ronment
,thehost,andt he
agent,
andstoppi
ngthecont
inuat
ionofdisease.

SO THE NURSE MUST BE AS WELL KNOWLEDGEABLE ABOUT THE CHAI

N OF
I
NFECTI
ON

TheCHAINofI
NFECTI ONrefer
stoaser i
esofevent
sthathast
ohappent
oenabl
eger
mst
hat
ar
ebact
eri
a,f
ungi
andv
iruses)t
ocauseinf
ect
ionsinaper
son.

Asexplai
ned,thetr
adit
ionalepi
demiol
ogi
ct r
iadhol
dst hatinf
ect
iousdiseasesr
esultfr
om theint
eract
ion
ofagent ,host,and envir
onment.More specifi
cal
ly,t r
ansmi
ssion occurs when the agentleaves
i
ts r
eserv
oir 
orhostthrougha port
alofexit,i
sconv eyedbysome  modeoft ransmissi
on,andenters
thr
oughanappr opr
iat
e port
alofent
ry 
toi
nfecta 
susceptibl
ehost.Thi
ssequencei ssometi
mescalledthe
chainofi
nfecti
on.

Ther
ear esixcomponent si nthei nfecti
ousdi seasepr ocess( also known ast hechain of
I
nfecti
on).
Ther
emustbeapat hogen.Exampl e:Vi
rus
Ther
emustasour ceofthepathogen( r
eser voir
).Exampl e:Andy( r
eservoir
)hasacol d
Ther
emustbeapor t
alofexit(t
hewayf orthepat hogent oescapef rom ther eser
voir)
.Example:
WhenAndybl owshisnose,coldvi
rusesgetintohishands.
Ther
emustbeamodeoft ransmission(thewayf orthepat hogent otr
av elfrom Andytoanother
person)
.Example:Andyisshakinghandswi thJoe,t hecoldv i
rusi sbeingtransferredtoJoe.Fr om his
handt othemucousmembr anesofhi snose.( andwoul dtheref or
e,notdev elopacol d)i fhehad
pr
evi
ousl
ybeeni
nfect
edbyt
hatpar
ti
cul
arcol
dvi
rusandhaddev
elopedi
mmuni
tyt
oit
.

Ther
emustbeaportalofentr
y(thewayfort
hepathogent
ogainent
ryi
ntoJoe.Exampl
e:When
Joer
ubshi
snose,
thecol
dvi
rusistr
ansferr
edf
rom hi
shandtothemucousmembranesofhi
snose.

Ther
emustbeasuscept
ibl
ehost.Joewouldnotbeasuscept
ibl
ehost(
andwoul
d,t
her
efore,not
dev
elopacol d)i
fhehadprevi
ouslybeeninfect
edbyt hatpar
ti
cul
arcoldvir
usandhaddev el
oped
i
mmunitytoit
.

Thef i
gurecl ear
lyi
ndicatest hatf orapersont ogeti
nfect
edwi thadiseaseorf orapersontoget
sick,achai nofeventhappens.Ger ms/ diseasecausingagent
sar eeverywhere; theyliveandmul t
ipl
yina
reservoirthatincludeshumans,ani mal s,soil,f
ood,andwat er.Thesedi sease- causingagentsgetout
from thereservoirf r
om apor talofexitlikemucuswi ththeagentcomesoutf rom t hemout hofaper son;
i
nf ectedbloodcomesoutf rom ani njuredwound. Oncet heycomeout ,t
hesei nfectedmucusorbl ood
aret r
ansmi tt
edthr oughdropletswhenonespeaks, coughsoutorthroughcont actwi thhandsorsoi l
.The
i
nf ecti
ont hengetsi ntoanotherper sont hr
oughapor t
alofentr
ysuchasmout h,wounds,andey esofa
suscept i
blepersonwhobecomesanot hersickpersonbecausehe/ shecontr
act edt heagent

Thereservoi
r
By‘ r
eser
voi
r’
,wemeanapl acewhereger
mscanl i
veandmul
ti
ply
.The‘ pl
ace’
canbeaperson–a
pat
ient
/cli
entoramemberofst af
f–butitcanalsobeanypartoft
hesurroundi
ngareaofahealt
hcar
e
set
ti
ng,fur
nishi
ngsi
nthepat
ient
’s/
cli
ent
’sr
oom andtheequi
pmentweuseinhealt
hcare.

Thepor t
alofexi tfrom ther eserv oi
r
The‘ portalofex i
t’ist hemeansbywhi cht heger m canescapef rom ther eser
voir
.Fori nstance,
thinkaboutsomeger ms( thei nfectiousagent )sitti
ngont opofausedcommode( thereservoir)
.Aheal th
car eworkercomesal ongandt ouchest hecommode,andsomeoft hegermsmov eontoherhands.The
heal t
hcarewor ker’shandsar enowt he‘portalofex i
t’–t hemeansbywhi chtheger msar eabl etomov e
from thecommodet oanot herpl ace.Ot her‘port
als’canbepeopl e’snormalex cr
et i
ons(stool
s, vomit
),body
fl
uids( bl
ood,sal i
va)andt heai rt heybreat hefrom t heirlungs,especiall
ywhent heycough.Thepor talcan
varyf r
om onei nfecti
ont oanot her( forex ampledi arrhealinfect
ionsar eusual
lypassedonv iathepat i
ent's
feces).Germscanev enbespr eadar oundont hetinyf lecksofskint hatpeeloffourbodiest hroughoutthe
dayandwhi chf orm partoft hedustt hatset tl
esonal lki
ndsofsur f
aces.Non- humanpor talsofex itfor
ger msincludei temsofequi pmentt hathav en’
tbeenpr oper l
ycleaned,suchascommodes, bedmat t
resses,
pill
owsandr eusabl eequipment .

Themodeoft ransmission
Thi
sishowt hegermsmov e,orspr
ead,f
rom oneplacetoanother
.Thiscanhappeninanumberof
ways,suchasheal t
hcar eworkers’handst
ouchi
ngdirtyequipmentorcontaminat
edmedicali
nst
rument
s,
ort
hroughtheair(coughs,sneezes).

Thepor t
alofentryintothe‘ host’
Thismeanst hattheger mst hathavebeenmov edfrom thereservoirnowi nvadetheper
son(the
‘
host’
).Theycandot hisbyent eri
ngwoundsandcut s,beingswall
owedandbei ngbr eat
hedin.
Pati
entswhoar ehav i
ngt reatmentsthati
nvol v
ecut t
ingtheski norpl aci
ngmedi cali
nst
ruments
i
nsidethebody ,suchasacat heterbeingplacedi
ntot hebladderoraf eedingtubebeingpasseddownt he
thr
oat,arealsoatri
skofi nfection.Anotherexampleispeoplewhoi nj
ectdr ugswi t
husedneedles.

Thesuscept iblehost
Healthypeopl ehav etheirowndef enseswhichhelpthem f i
ghtinfect
ion.Thismeanst hatevenif
somehar mf ulgermsent erthebody ,thepersoncan‘fi
ghtthem off’
andst aywell.Theabi
li
tyoft hebodyt o
defendi tsel
fagai nstinf
ectioniscal l
ed‘immunity’
.Somepeopl e,however,can’tfi
ghtinf
ecti
onef f
ect
ively.
Thesei ncludev eryyoungchi l
dren,olderpeopl
e,peopl
ewhoar ei l
lorwhoar ereceivi
ngpart
icularmedicines
thatr educet hei
rimmuni t
y,peopl ewi t
hlong-ter
m healt
hcondi ti
onslikedi abetesandt hosewhoar e
physicall
yweakduet o,f orinstance,malnutr
it
ionordehydrati
on.Peopl esuchast hesear e‘susceptibl
e
host
s’–meani
ngt
heyar
evul
ner
abl
etodev
elopi
ngi
nfect
ionwhent
hei
rbodi
esar
einv
adedbyger
ms.

Theinfectiousagent
Thei nf ect
iousagenti ssimpl
ytheger mt hatcausest he
i
nfecti
on.Ger msar eallaroundusandwi t
hinus,andmanypl ay
ver
yi mpor tantr ol
esi nkeepingushealthy
.Thepr oblem comes
whenager ml eavesitsnor malpl
acetogoel sewhereinthebody
–theger mst hatsitony ourski
nandwhichusuallycausenohar m,
forinstance,get t
ing into a cut
.The germ coul dt hen cause
i
nfecti
on.Ther earealsomanyger msthatarenothel pf
ultohealth
andwhi chcausedi sease.Entryofanyoft heseger msi nt
ot he
bodyislikelytocausepr obl
ems.

ELABORATE
Anel
abor
ati
onoft
heepi
demi
ologi
ctr
iadandchai
nofi
nfect
ionbyl
ooki
ngi
ntot
heCOVI
D-19Pandemi
cis
pr
ovi
dedtot
hefol
l
owi
ngpart
softhemodule.

THECOVI D-19PANDEMI C
Thecoronav
irusdisease2019( COVID-19)isaninfecti
ousdiseasecausedbysever
eacut
e
respi
rat
orysyndromecoronavi
rus2(SARS-CoV-2),anewstr
ainofv i
rusf
ir
stdet
ectedi
nWuhan,Chi
nai
n
2019.

COVID-
19 i
sknown t otargeta per
son’srespi
rat
orysy
stem.Inf
ected pat
ient
smayexhi
bit
symptomssuchasf ev
er,cough,short
nessofbreat
h,andinsomecases,muscl
epainandsor
ethr
oat.
Some pat ients may al so be
asymptomatic.

On March 11,2020,t he
World Healt
h Organizat
ion (WHO)
has charact
eri
zed COVID-19 as a
pandemic due tot he exponent
ial
i
ncreaseoft henumberofcasesi n
morethan100count ri
es.
 OnMar ch16,2020.Pr esidentRodr i
goRoaDut ert
eplacedt heent i
rePhili
ppinesunderaStateof
Cal
ami t
yami dthet hreat
sposedbyCOVI D-19.
Thef i
gureabov eshowst hatt heAgenti st heCor onav i
rus. TheHostar eal lagesespecial
lythe
vul
nerablepeopl el i
kechildren,el derly
,andi mmunocompr omisedi ndi
viduals(ex:cancerpati
ents)
.The
envi
ronment–Thev irusstartedi nChi naspeci fi
call
yWuhanMar ket.Ifwel ookintot heenvi
ronmentof
WuhanMar ket,itissamei nPhi l
ippineswher et herearear
easofov er
crowdinglikeinchurches,j
eepneys,
market,ai
rplane, et
c.Whatt henar et hedif
ferentcomponent softheChai nofInfecti
onoft heCoronavir
us?
Whatshoul dbedonet obreakt hechai nofinfect i
on?

ChainofI nf ect ionoft heCov id- 19Pandemi c

Coronav ir
usDi sease2019( COVI D-19)i san
i
nfectiousdi seasecausedbyanew
coronavirusr ecent lyi
ntroducedt ohumansf or
thefir
stt i
me.TheWor l
dHeal thOr ganization
(WHO)hascal ledi tapandemi c.Thi smeans
thatthev i
rushasspr eadal lov ert hewor ld.
About80%oft hosewhohav eCOVI D-19hav e
mildsy mpt oms.
Coronav ir
usesar eal argef ami lyofv i
ruses
causing a r ange of i l
l
nesses, f rom t he
commoncol dt omor eser i
ousi nfecti
onssuch
ast hosecausedbyMi ddleEastRespi ratory
Syndrome- related Cor onav irus ( MERS- CoV)
and Sev ere Acut e Respi rator y Sy ndr ome-
rel
atedCor onav i
rus( SARS- CoV) .Cor onav irus
canal socauseav ari
etyofdi seasesi nf arm
animalsanddomest i
catedpet s.
Mostcommonsy mpt omsar e: 
 Fev er( notnecessar il
yahi ghfev er
 Dr ycough
 Ti rednessorf ati
gue
 Shor tness of br eat h or di ffi
cul t
y
breat hing
 Somepat ient
sexper ienceachesandpai ns,
nasal
congest
ion,
runnynose,
sor
ethr
oat
,ordi
arr
hea
 
SevereSympt omsi ncl
ude:
 Diff
icultybreat
hingorshortnessofbreath
 Persistentpainorpressur
ei nthechest
 Ment alconfusionorchangesinalert
ness
 Blui
shl ipsorface
 
Sy
mptomsofCOVI D-19canrangef r
om mildtosever
e.Ar
ound80%ofpeopl
ehav
emi
l
dsy
mpt
oms.I
t
takesatmost14day sforsymptomsofCOVI D-
19t oshow.

Ifanindi
vi
dualhastheseandl iv
einapl aceunderECQorhav erecentl
ytr
av el
edto/
from aplace
underECQ,callt
helocalBarangayHealthEmergencyResponseTeams( BHERTort heDepartmentof
Healt
h(DOH)hotli
ne-(02)894COVI D(26843)or1555forallnet
worksubscri
bers.Theywi
llassessand
advi
setheneedtoseekmedicalatt
enti
onandwhi chnear
esthealt
hfaci
l
ityyoushouldgoto.

Peopl eofal lages  canbei nfectedwi thCOVI D- 19. 

a.Groupst hatar eathi gherr iskofdev elopingsev ereill
nessi nclude:
-Peopl e65y ear soldandol der(ourlol osandl olas)
-Any onewi thpr e-existingmedi calcondi ti
ons( exampl e:hi
ghbl oodpr essure,heartorlung
disease, ordiabet es)
-Thosewi thhi gh-ri
skpr egnancies( exampl e:womenaged17andy ounger ,aged35andol der,
thosewi thpr e-existi
ngmedi cal conditi
ons)
-COVI D-19i st ransmi tt
edf rom per sont oper sont hr
oughdr opl
ets.Itistransmi t
tedwhenone
i
ndi v
idualt alks,sneezes,orcoughspr oducing‘ droplets’ofsal i
vacontai
ningt heCOVI D-19vir
us.These
dropletsar etheni nhal edbyanot herperson.
-COVI D-19t ransmi ssionusual lyoccur samongcl osecont act
s--includi
ngf amilymember sand
healthcarewor kers.Iti sthereforei mpor t
antt omai ntainadi stanceofmor ethan1met erawayf r
om any
personwhohasr espir ator
ysy mpt oms.
-Aper soncanal socat chCOVI D-19byt ouchingobj ectsorsurfaces,thent ouchi
ngtheireyes,
nose, ormout h.Thisi swhyi tisimpor t
antt or egularlywashy ourhands.

Whatar ethenewcl assificationsofi ndividual sforCOVI D-

19?
1. Suspect;
2. Probable; and,
3. Confir
med.
PersonsUnderI nv esti
gati
ons( PUI )wi llnow becl assi f
iedas  suspect 
or 
probable.Peopl
ewho
tested 
posi t
ive 
forCOVI D- 19 wi l
lbecl assi fi
ed as  confir
med. Thi si st o al
ignthePhi l
i
ppi
nes'case
classif
icati
onwi ththedef init
ionsoft heWor ldHeal thOr ganizat i
on( WHO)t ohaveamor eunif
ormed
reporti
ngmechani sm acrosscount ri
es.
 
Ani ndivi
dualhasr espir
at orysy mpt oms.Wi llhe/ shebecl assi f
iedas  suspect?
He/shearedef i
nedasaper sonwhoi s suspect wit
hCOVI D-19if: 
- Hasani nfluenza-l
ikeillness( I
LI)thatmani festswi thfever(38°C),coughorsorethr
oat,
andhav eanyoft hef oll
owi ng:  
a. Travelhistoryt oanar eawi thl ocaltransmi ssionofCOVI D-
19dur i
ngthe14day sbefor
e
symptomsbegan; or ,
b. Hist
oryofcl osecont actwi thper sonpr obabl eorconf irmedwi t
hCOVI D-19dur
ingthe14
daysbef oresy mptomsbegan.

- Hasf ever,
cough, orotherr
espir
atorysymptoms,andbel
ongt
ovul
ner
ablepopulati
ons:
 
a.Thoseaged60y earsandabov e;
b.Thosewit
hpr e-
existi
nghealthcondit
ions;
c. Thosewithhigh-
r i
skpregnanci
es;and, 
d. Healt
hwor ker
s
e. Youdev el
opedsev er
eandacut erespir
ator
yil
l
nesswi t
hnoexpl
ainabl
eetiologythat
 requiresov er nighthospi talizat i
on.
 
Whocanbeconsi deredpeopl e probabl e wi thCOVI D- 19?
A per soni scl assifiedas  pr obabl e  wi thCOVI D-19i ftheper sonwasor iginall
y suspect ed wit
h
COVI D-19andt heir: 
a.Testt urnedouti nconcl usive; or
b. Testwasdonei nanon- of fi
cial RT- PCRl abor at
ory.
 
Whocanbeconsi deredpeopl e conf i
rmed  wi thCOVI D- 19?
A per soni s confirmed  withCOVI D- 19i ft heirsampl essentf ort est i
ngt oof ficiallaboratori
es
returnedposi tiveusi ngt heRT- PCRmet hod.
 
Whowi llbet est edf orCOVI D- 19?  
Youwi l
lbet estedf orCOVI D- 19i fy ouar eei ther  
suspect  
or  probabl e 
withCOVI D- 19.Howev er,
prioritywi llbegi vent ot hosewi thsev er ei l
lness,aswel laspeopl e suspect  
wi thCOVI D- 19,andwi t
h
history ofcont actwi th peopl e probabl e or  conf i
rmed  wit
h COVI D- 19 14 day s bef oret he onsetof
sympt oms.  
 
Wi l
lther ebechangesi nthemanagementandt reat mentofCOVI D-19?
Prot ocol sf ormanagementandt reat mentwi llremainandar ebasedont hesev erityofsy mpt oms.
 
Ani ndi viduali saPer sonUnderMoni toring( PUM) .Whatshoul dhe/ shedonext ?
14- daysel f -
quarant i
neathomemustst illbepr acti
cedi fhe/ shehasahi storyofexposur etoa 
per sonpr obabl eorconf i
rmedwi thCOVI D- 19,ort rav elhistorytoapl aceorcommuni tywi thconfir
med
COVI D-19cases.
 
Ani ndi viduali saPUIwi thmi l
dsy mpt oms.Whatshoul dhe/ shedonext ? 
Prev i
ousl ycl assi fi
edPUI swi t hmi l
dsy mpt omswi l
lbecl assifi
edas  suspect  wi thCOVI D- 19andshal l
fi
nisht heir14- daysel f-
quar ant inei nt hei rhomesori nt hei
rlocalTempor aryTr eat mentandMoni tori
ng
Faci l
ity.
 
Ani ndi vi
duali saPUIwi thsev eresy mpt oms.Whatshoul dhe/ shedonext ? 
Prev iousl ycl assi fi
edPUI swi thsev er esy mpt omswi llneedt est i
ng.He/ sheneedst obeadmi ttedt oa
Lev el2orLev el3hospi t
al.
 
Istest ingf ree?
Yes, test i
ngi sf ree.Howev er, testingi sonl yr equi r
edf or suspect  
cases.  
 
Howdoesani ndividualgett est edi fIhe/ shei sa  suspect  
case?
He/ shewi ll ber efer r
edt oaLev el2orLev el 3hospi tal tohav ethef ollowi ngsampl est aken:
a.Nasophar yngeal swab( sampl ei stakenf rom t hebackoft henoseandt hr oat);
 
b. Or ophar yngeal swab( sampl ei st akenf rom t het hroat).
 
 
Whoshoul dbesenthome?  
Peopl ewhoar e suspect  or probabl e  wi t
hCOVI D-19shoul dber eferredt oa  Tempor aryTreatment
andMoni t
or ingFaci lit
yorbesenthomef orst rict14- dayhomequar antine.Non- COVI D-19pat ientsare
alsoadv isedt ogohome.
 
Wi l
lani ndivi dualbeal lowedt ogohomewhi lewai ti
ngf orhis/hert estr esul ts?
Ifhe/ shehasonl yhasami l
dsy mpt om, he/ shewi l
lbei nstruct edt ounder goast r
ict14-dayhome
quar ant i
ne.Pat i
ent smani fest ingsev er esy mpt omswi llrequirehospi tal i
zation.
 
Ishospi talizat i
onneededf or suspect  pat i
ent s?
Peopl e suspect  
wi t
hCOVI D- 19wi thmi ldillnessneednotbehospi tal i
zed.Theymaybesenthome
afterbei ngt est ed, butareadv isedt or eturnwhensy mpt omswor sen.