Essentials of

Community Medicine

(1)

1
 Part (1)
Introduction to
Prevention & Control
of Communicable
Diseases

2
 By
Prof M Hany soliman
Prof in department of Public Health,
Community Medicine &
Industrial Medicine,
AL-AZHAR FACULTY OF MEDICINE,
CAIRO, EGYPT

3
 ‫مقدمة‬
‫الحمد هلل رب العالمين والصالة والسالم على أشرف المرسلين‬
‫وبعد ‪.....‬‬ ‫وعلى آله وصحبه أجمعين‬
‫هذا هو الجزء األول من كتاب الطب الوقائي لطلبة كليات‬
‫الطب‪ .‬وسوف يتلوه أجزاء أخري‪ .‬وانصح الطالب بقراءة الفهرس‬
‫(في نهاية الكتاب) واختيار المواضيع المطلوب منهم دراستها في‬
‫كليتهم‪ ،‬كما انصحهم بالرجوع إلى قناتي على اليوتيوب لمزيد من‬
‫الشرح والفهم‪ ،‬اسمها‪hany soliman :‬‬
‫وهذا الجزء يحتوي على مقدمة الطب الوقائي والتي تشتمل‬
‫على القواعد العامة لفهم ووصف األمراض والوقاية منها‪.‬‬
‫يعقب ذلك اهم المصطلحات الالزمة لممارسة الطب الوقائي ثم‬
‫القواعد األساسية لمكافحة العدوي‪ ،‬كل ذلك باللغة اإلنجليزية‪.‬‬
‫ا‪.‬د‪ .‬محمود هانئ حسن‬
‫أستاذ بقسم‪ /‬الصحة العامة‬
‫وطب المجتمع وطب الصناعات ‪ ،‬بكلية طب األزهر ‪ -‬القاهرة‬
‫‪4‬‬
5
 Preface
This is the first part of the book for Community
Medicine, Preventive Medicine & Public Health.
Basically, it is intended to help students &
post-graduates of Faculty of Medicine to work
according to the scientific rules. However, students
of medicine in different other faculties can use it.
These faculties are: faculty of medicine, nursing
faculty, faculty of dentistry, pharmacy faculty, vet
faculty. Any other person dealing with public
health can use it to study these subjects.
You will find also, some summarized clinical
information to help you when practicing
preventive medicine.
At end you will find a glossary of important
terms & appendices containing main principles for
infection control.

6
 FIRST PART
Introduction to community medicine,
public health & preventive medicine

Objectives
• After studying this chapter, you will be able to:
1. Define the terms health, community, community health,
population health, public health, public health system, and global
health.
2. Briefly describe the five major determinants of health.
3. Explain the difference between personal and community health
activities.
4 f r f ’ health.
• Since 1900, tremendous progress had been made in the health
and life expectancy of many people of the world since 1900.
Infant mortality dropped, many of the infectious diseases have
been brought under control, and better family planning became
available.
• However, much still needs to be done to improve health
especially when it comes to health disparities found in certain
parts of the world and racial groups. Individual health behaviors,
such as the use of tobacco, poor diet, and physical inactivity, have
given rise to an unacceptable number of cases of illness and death
from noninfectious diseases such as cancer, diabetes, and heart
disease. Continued use of an outdated infrastructure, such as the

7
 old water pipes in Flint, Michigan, has exposed many to
unnecessary health risks.
• New and emerging infectious diseases, such as Zika virus disease
and those caused by superbugs (i.e., drug-resistant
pathogens), are stretching resources available to control them.
And events stemming from natural disasters such as floods,
tornadoes, and hurricanes; human-made disasters such as the
Gulf oil spill; and terrorism caused to refocus our priorities. All of
these events have severely disrupted sense of and sense of safety
in the environment.
• Even with all that has happened in recent years around the world,
the achievement of good health remains a worldwide goal of the
twenty-first century. Governments, private organizations, and
individuals throughout the world are working to improve health.
Although individual act r v ’ r
certainly contribute to the overall health of the community,
organized community actions are necessary when health
problems exceed the resources of any one individual. When such
actions are not taken, the health of the entire community is at
risk.
This chapter introduces the concepts and principles of community
and public health, explains how community and public health
differ from personal health, and provides a brief history of
community and public health.

8
 Definitions
The word health means different things to different people.
Similarly, there are other words that can be defined in various
ways. Some basic terms we will use in this book are defined in the
following paragraphs.
• Health
The most widely quoted definition of health was the one created
by the World Health Organization (WHO) in 1946, which states
“ f , , -
r f fr ”
Further, the WHO has indicated tha “ a resource for
everyday life, not the object of
living, and is a positive concept emphasizing social and personal
resources as well as physical
”
• Others define health as a dynamic state or condition of the
humans that is multidimensional (i.e., physical, emotional, social,
intellectual, spiritual, and occupational) in nature, a resource for
v , r fr r ’ r
adaptations to his or her environment. Therefore, it can exist in
varying degrees and is specific to each individual and his or her
“ r v r j r
healthy or at least feel well. There are many examples, but
r rr r f r ”
• Health is not an end, but means to another end = live socially &
economically a productive life. Definition, of health has 3
dimensions: physical, mental & social.

9
• Nonmedical dimensions included are spiritual, emotional,
vocational & political dimensions.
• POSITIVE HEALTH
A person who is healthy physically, mentally & socially (&
r ) f ‘P v ’, r f
health.
Thus, enjoying a state of health:
• f human right
• f productive life
• integral part of development
• central to concept of quality of life
• world-wide social goal
• WELL-BEING
Well-being of an individual has 2 components, objective &
subjective.
Objective Component
r ‘Standard of living’, educational
level, income, occupational status, standard of housing, nutrition,
sanitation, dress & other comforts of modern living.
• This primarily depends of GNP (Gross National Product) includes
gross income generated in country as well as net income received
from abroad.
• Subjective Component
This relates to ‘Quality of life’, & determined by a combination of
factors as health, happiness, education, social & intellectual
attainments, freedom of action, justice & expression.
Quality of life can be evaluated by a composite index called
‘physical quality of life index’ (PQLI) & it contains 3 indicators viz
infant mortality rate, life expectancy at age one & Literacy. PQLI
10
 is used for national & international comparison of human well-
being.
For each component, performance of individual countries is placed
on scale of 0 to 100, where ‘0’ represents ‘worst’ performance &
100 represents ‘best’ performance & 50 represents ‘average’.
• The composite index calculated by taking average of all 3
indicators, giving equal weight to each of them. Resulting PQLI is
thus scaled from 0 to 100, as follows:
a. IMR weightage is on scale of 0-100. Zero is for an IMR of
220/1000 live-births & 100 for 7/1000 live-births. This is referred
to weighted IM ‘ ’
b. Weightage of life-expectancy at age 1 is on scale of 0-100 It is
r f r 38 & 100 f r 77 r f rr ‘ ’
• r r r r f rr ‘ ’

• PQLI does not depend upon /capita GNP, unlike standard of living,
‘money is not everything ’
• For example, Middle East oil rich countries ē high/ capita income,
have low PQLI, whereas Sri Lanka ē low per capita income have
high PQLI.
• Thus, PQLI does not measure economic growth of a country but it
measures results of social, economic & political policies.
The ultimate objective is to attain a PQLI of 100.

11
• The term community medicine is only a new terminology. It is the
successor of the terms: hygiene, preventive medicine, social
medicine & public health.
• HYGIENE
r v fr Gr k r ‘ ’=G f
• f ‘ f & embraces all factors contributing
to healthful living’.
• r, ‘P ’ r r maintenance &
improvement of health of people.
• P =‘ & r f r v , r f &
promoting health & by organized community efforts, as control of
communicable disease, sanitation, health education, etc.
• to enable every citizen to realize his birth-right of health &
longevity’.
• So, importance of preventing disease was highlighted.
• applied to healthy persons so as to prolong life.
• PREVENTIVE MEDICINE
defined preventive medicine as ‘science & art of preventing
disease, prolonging life & promoting physical & mental health
and efficiency’.
• r ’ r f
ff r f r r ’
that health status is determined by the interaction of five
domains: gestational endowments (i.e., genetic makeup), social
circumstances (e.g., education, employment, income, poverty,
housing, crime, and social cohesion), environmental conditions
where people live and work (e.g., toxic agents, microbial agents,

12
 and structural hazards), behavioral choices (e.g., diet, physical
activity, substance use and abuse), and the availability of quality
medical care.
• “ , f f f r f r
acting not mostly in isolation but by our experience where
domains interconnect.
• Whether a gene is expressed can be determined by
environmental exposures or behavioral patterns. The nature and
consequences of behavioral choices are affected by social
circumstances. Our genetic predispositions affect the health care
we need, and our social circumstances affect the health care we
r v ”

13
• “Community" is a group of people living together permanently in a
defined or definite geographic area having common goals or
j v ”
• Community is a social group with some degree of we felling &
living in given area. OR
• “ f r f v rk
r f r ”
• r ff r ,
activities background lies in the same locality so that there is
interaction between them. OR
• Community refers to a group of people habiting in a limited area,
who have feelings of belonging together & who through their
relationship share & cares on activities in pursuit (Search) of their
common interest.
Elements of community
1. Group of people
2. Living together permanent in a specific geographical area
3. Sense of belongings
4. Naturality
5. Likeness/common understanding
6. Interpersonal relationship
7. Social institution
8. Cultural- historical heritage
Public health: actions that society takes collectively to ensure that the
conditions in which people can be healthy
Public health system: the organizational mechanism of those activities
undertaken within the formal structure of government and the
associated efforts of private and voluntary organizations and individuals
14
Community health: the health status of a defined group of people and
the actions and conditions to promote, protect, and preserve their
health
Population health; “the health outcomes of a group of individuals,
r f r ”
Global health: describes health problems, issues, and concerns that
transcend national boundaries, may be influenced by circumstances or
experiences in other countries, and are best addressed by cooperative
actions and solutions
Personal Health Activities
Personal health activities are individual actions and decision-making
that affect the health of an individual or his or her immediate family
members or friends. These activities may be preventive or curative in
nature but seldom directly affect the behavior of others. Choosing to
eat wisely, to regularly wear a safety belt, and to visit the physician are
all examples of personal
health activities.
Community and Public Health Activities
Community and public health activities are activities that are aimed at
protecting or improving the health of a population or community.
Maintenance of accurate birth and death records, protection of the
food and water supply, and participating in fund drives for voluntary
health organizations such as the American Lung Association are
examples of community health activities

15
 Factors Affecting Health of a Community
Many factors affect the health of a community. As a result, the health
status of each community is different. These factors may be physical,
social, and/or cultural. They also include the ability of the community to
organize and work together as a whole as well as the individual
behaviors of those in the community (see coming

Physical Factors
Physical factors include the influences of geography, the environment,
community size, and industrial development.
Geography
’ r r f
altitude, latitude, and climate. In tropical countries where warm, humid
temperatures and rain prevail throughout the year, parasitic and
infectious diseases are a leading community health problem. In many
tropical countries, survival from these diseases is made more difficult
because poor soil conditions result in inadequate food production and

16
malnutrition. In temperate climates with fewer parasitic and infectious
diseases and a more than adequate food supply, obesity and heart
disease are important community and public health problems.
Environment
The quality of our natural environment is directly related to the quality
of our stewardship of it. Many experts believe that if we continue to
allow uncontrolled population growth and continue to deplete
nonrenewable natural resources, succeeding generations will inhabit
communities that are less desirable than ours. Many feel that we must
accept responsibility for this stewardship and drastically reduce the
rate at which we foul the soil, water, and air.
When speaking about the environment we must also consider the
impact the built environment has on community and public health. The
term: built environment r f r “ , r ,
management, and land use of human-made surroundings as an
interrelated whole, as well as their relationship to human activities over
tim ”
transportation systems (e.g., mass transit); urban design features (e.g.,
bike paths, sidewalks, adequate lighting); parks and recreational
facilities; land use (e.g., community gardens, location of schools, trail
development); building with health-enhancing features (e.g., green
roofs, stairs); road systems; and housing free from environmental
hazards. The built environment can be structured to give people more
or fewer opportunities to behave in health enhancing ways.
Community Size
The larger the community, the greater its range of health problems and
the greater its number of health resources. For example, larger
communities have more health professionals and better health facilities
than smaller communities. These resources are often needed because
communicable diseases can spread more quickly and environmental
17
problems are often more severe in densely populated areas. For
example, the amount of trash generated by the approximately million
people in New York City is many times greater than that generated by
the entire state of Wyoming, with its population of.
r ’ z v v
v ’ f
community to effectively plan, organize, and utilize its resources can
determine whether its size can be used to good advantage.
Industrial Development
Industrial development, like size, can have either positive or negative
effects on the health status of a community. Industrial development
provides a community with added resources for community health
programs, but it may bring with it environmental pollution and
occupational.
Injuries and illnesses. Communities that experience rapid industrial
development must eventually regulate (e.g., laws and ordinances) the
way in which industries:
(1)obtain raw materials, (2) discharge by-products, (3) dispose of
wastes, (4) treat and protect their employees, and (5) clean up
environmental accidents.
Unfortunately, many of these laws are usually passed only after these
communities have suffered significant reductions in the quality of their
life and health.
Social and Cultural Factors
Social factors are those that arise from the interaction of individuals or
groups within the community. For example, people who live in urban
communities, where life is fast paced, experience higher rates of stress-
related illnesses than those who live in rural communities, where life is
more leisurely. On the other hand, those in rural areas may not have
18
access to the same quality or selection of health care (i.e., hospitals or
medical specialists) that is available to those who live in urban
communities.
Cultural factors arise from guidelines (both explicit and implicit) that
v “ r ” fr r f r r f
the factors that contribute to culture are discussed in the following
sections.
Beliefs, Traditions, and Prejudices
The beliefs, traditions, and prejudices of community members can
affect the health of the community. The beliefs of those in a community
about such specific health behaviors as exercise and smoking can
influence policy makers on whether or not they will spend money on
bike lanes on the roads and recreational bike trails and work toward
no-smoking ordinances. The traditions of specific ethnic groups can
influence the types of food, restaurants, retail outlets, and services
available in a community. Prejudices of one specific ethnic or racial
group against another can result in acts of violence and crime. Racial
and ethnic disparities will continue to put certain groups, such as black
Americans or certain religious groups, at greater risk.
Economy
Both national and local economies can affect the health of a community
through reductions in health and social services. An economic
downturn means lower tax revenues (fewer taxes) and fewer
contributions to charitable groups. Such actions will result in fewer
dollars being available for programs such as welfare, food stamps,
community health care, and other community services. This occurs
because revenue shortfalls cause agencies to experience budget cuts.
With fewer dollars, these agencies often must alter their eligibility
guidelines, thereby restricting aid to only individuals with the greatest
need. Obviously, many people who had been eligible for assistance
19
before the economic downturn become ineligible.
Employers usually find it increasingly difficult to provide health benefits
for their employees as their income drops. Those who are unemployed
and underemployed face poverty and deteriorating health. Thus, the
cumulative effect of an economic downturn significantly affects
the health of the community.
Politics
Those who happen to be in political office can improve or jeopardize
the health of their community by the decisions (i.e., laws and
ordinances) they make. In the most general terms, the argument is over
greater or lesser governmental participation in health issues. For
example, there was a longstanding discussion on the extent to which
the government should involve itself in health care.
Religion
A number of religions have taken a position on health care and health
behaviors. For example, some religious communities limit the type of
medical treatment their members may receive. Some do not permit
immunizations; others do not permit their members to be treated by
physicians. Still others prohibit certain foods. For example, kosher
dietary regulations permit Jews to eat the meat only of animals that
chew cud and have cloven hooves and the flesh only of fish that have
both gills and scales, while still others, like the Native American Church
of the Morning Star, use peyote, a hallucinogen, as a sacrament. ‫سر‬
‫مقدس‬
Some religious communities actively address moral and ethical issues
such as abortion, premarital intercourse, and homosexuality. Still other
religions teach health-promoting codes of living to their members.
Obviously, religion ff ’ v r
negatively.

20
Socioeconomic Status
ff r ( ), r“ f
education, employment, or income, both individual- and community-
v v ff ”
• There is a strong correlation between SES and health status—
individuals in lower SES groups, regardless of other
characteristics, have poorer health status. This correlation applies
both across racial groups and within racial groups
• Community Organizing
The way in which a community is able to organize its resources
directly influences its ability to intervene and solve problems,
including health problems. Community organizing “ r
by which community groups are helped to identify common
problems or change targets, mobilize resources, and develop and
r f rr r v ” 4
not a science but an art of building consensus within a democratic
process. If a community can organize its resources effectively into
f f r , “ k r f f r f
increased effectiveness and productivity by reducing duplication
of efforts and avoiding the imposition of solutions that are not
r r ” r x ,
communities in the United States have faced community-wide
drug problems. Some were able to organize their resources to
reduce or resolve these problems, whereas others have not.

21
• Individual Behavior
The behavior of the individual community members contributes
to the health of the entire community. It takes the concerted
effort of many—if not most—of the individuals in a community to
make a program work. For example, if each individual consciously
recycles his or her trash each week, community recycling will be
successful. Likewise, if each occupant would wear a safety belt,
there could be a significant reduction in the number of facial
injuries and deaths from car crashes for the entire community. In
another example, the more individuals who become immunized
against a specific communicable disease, the slower the disease
will spread and the fewer people will be exposed. This concept is
known as herd immunity

• What is community diagnosis?

• r v f
state of an entire community in relation to its economic, social,
physical & biological environment.
• a process or examining the
pattern of disease in the community & describing it in terms of its
importance factors. Such as population situation morbidity,
mortality, fertility rate
r v r ”

22
SOCIAL MEDICINE
Social medicine is defined as, ‘The study of man as a social
being in his total environment’ (Physical, biological and social
environment). Thus, social medicine became an extension of
preventive medicine.
• Epidemiology is study of distribution & determinants of health-
related states & events in specified populations
• Application of this study to control of health problems
• So, practice of epidemiology = scientific process to detect,
investigate, & analyze health problems,
• followed by applying this information to control & prevention of
these problems.
• Evaluation of control & prevention is also within this practice
communication of the findings to public, policy makers, &
program staff.

23
24
 SURVEILLANCE = observation
Definition
Because it is at beginning of epidemiological sequence, it is imp
“ rv ongoing systematic collection, analysis, &
interpretation of health data essential to planning, implementation, &
evaluation of PH practice,
closely integrated ē dissemination of these data to whom it may
concern make the link bet surveillance ē prevention & control efforts.

25
Characteristics of a Surveillance System
An effective system of PH surveillance has 7 items:
1. Simplicity
2. Acceptability
3. Sensitivity
4. Timeliness ‫توقيت‬
5. High predictive value positive (PVP)
6. Flexibility
7. Representativeness

26
• Interpretation of surveillance
Interpreting epidemiological data requires that causal associations
between exposure and outcome be correctly identified using
specific objective criteria. Although we have focused on the
measurement of association, the identification of bias, and the
role of chance up to this point, these criteria include, but go
beyond, measurement and chance.
The initial criteria used to distinguish causal associations from
indirect and artifactual ones were applied to a study of epidemic
infections can be stated as follows:
1. The causative agent must be recovered from all individuals with
the disease.
2. The agent must be recovered from those with the disease and
grown in pure culture.
3. The organism grown in pure culture must replicate the disease
when introduced into susceptible animals.
Such rigorous criteria ensure that studies adhering to them are
very likely to identify causal associations correctly. Nonetheless,
they are restrictive, and, had they been adhered to inflexibly,
some important epidemiological associations would not have
been found. The association of smoking and lung cancer is one.
• Use of criteria similar to those proposed. These criteria can be
summarized as follows:
1. Chronological relationship: Exposure to the causative factor
must occur before the onset of the disease.
• 2. Strength of association: If all those with a health problem have
been exposed to the agent believed to be associated with this
problem and only a few in the comparison have been so exposed,
the association is a strong one. In quantitative terms, the larger

27
 the relative risk, the more likely the association is causal.
3. Intensity or duration of exposure: If those with the most
intense or longest exposure have the greatest frequency or
severity of illness while those with less exposure are not as ill,
then the association is likely to be causal. This can be measured by
showing a biological gradient or a dose-response relationship.
• 4. Specificity of association: If an agent, or risk factor, can be
isolated from others and shown to produce changes in the
frequency of occurrence, or severity of the disease, the likelihood
of a causal association is increased.
5. Consistency of findings: An association is consistent if it is
confirmed by different investigators, in different populations, or
by using different methods of study.
6. Coherent‫ متماسك‬and plausible‫ معقول‬findings: This criterion is
met when a plausible relationship between the biological and
behavioral factors related to the association support a causal
hypothesis. Evidence from experimental animals, analogous
effects created by analogous agents, and information from other
experimental systems and forms of observation are among the
kinds of evidence to be considered.

28
 Using Judgment in Analysis
The following points are important when applying judgment to
epidemiological analysis. They are:
1. Start with data of good quality and know the strength and
weakness of the data set in detail.
2. Make careful description of the first step.
3. Determine the population at risk as precisely as possible.
4. Selecting the comparison, or control, group is one of the most
difficult judgments to make. As a rule, try to choose subjects
for comparison who represent the case group and come from the
place where the exposure under study is most likely to
have occurred.
5. Reduce the data analysis to a 2 × 2 table where possible.
6. The strongest case for an epidemiological association is one
that meets all of the causal criteria.
7. Carefully determine the role that bias, including confounding,
may have played in distorting an association.
8. In assessing an association, do not rely on tests of statistical
significance alone. Remember the words of Sir Austin Bradford
…“ r r r they
[tests of statistical significance] are totally unnecessary—
because the difference is grotesquely obvious, because it is
negligible, or because, whether it be formally significant or not, it
is too small to be of any practical importance.
• Information Bias
Information bias occurs when there are systematic differences in
the way data are gathered from controls and cases. For example,
if one set of questions is used to evaluate the exposure in the
control subjects, and another set is used for the case subjects, the
information about the groups may differ systematically. This could

29
easily lead to distorted inferences. If, in a clinical study, one group
is observed more frequently than another, the probability of
making an observation will be greater in the one observed more
frequently. This kind of
bias could occur in a study comparing the effectiveness and safety
of two approaches to patient care. If one approach was used for
subjects seen in an ambulatory clinic while the other required
hospitalization,
those in the hospital might be seen more frequently than those in
the clinic. Information bias may include observer, interviewer,
measurement, recall, or reporting bias. Definitions of these terms
are discussed in detail in other writings.

30
 Principles of infectious disease
Epidemiology ‫هام‬
General Terms & Definitions

Infection & Infectious Disease

• = entry & development or multiplication of an infectious agent in
human (or, animal) ē response (e.g., immunological response) in
human or animal.
• “ f ” “ f ”
• Infectious dis is r f“ f ” clinically apparent
• Pr v r “ f ”& - including
subclinical cases, carriers, reservoirs or infectious agent & its
modes of transmission & “ f ”.
• = entry & development or multiplication of an infectious agent in
human (or, animal) ē response (e.g., immunological response) in
human or animal.
• “ f ” “ f ”
• f r f“ f ” clinically apparent
• Pr v r “ f ”& - including
subclinical cases, carriers, reservoirs or infectious agent & its
modes of transmission & “ f ”.
• = entry & development or multiplication of an infectious agent in
human (or, animal) ē response (e.g., immunological response) in
human or animal.
• “ f ” “ f ”
• f r f“ f ” clinically apparent

31
• Prevention is interested in “ f ”& - including
subclinical cases, carriers, reservoirs or infectious agent & its
modes of transmission & “ f ”.
• Infestation: in humans, animals or personal items, where it =
either
• presence & development of insect vectors on body or linen (e.g.
louse infestation) or
• on mucus membranes e.g., roundworm infestation
• Infestation also used for describing when accommodation or
articles (as containers) have presence of arthropods or vectors
(e.g., cockroach or rat infestation in houses)
• Infestation: in humans, animals or personal items, where it=
either
• presence & development of insect vectors on body or linen (e.g.,
louse infestation) or
• on mucus membranes e.g., roundworm infestation
• Infestation also used for describing when accommodation or
articles (as containers) have presence of arthropods or vectors
(e.g., cockroach or rat infestation in houses)
Dead-End Infection:
• f “ ”, cannot be
transmitted any further bet human beings or from humans to
animals or v v r ← v r , & vr
reasons
Examples are: Japanese Encephalitis, Rabies, Tetanus, Bubonic
plague, Scrub typhus in humans.
Subclinical Infection (Inapparent infection)
• When agent multiply in host body, but there are no clinical
manifestations of dis

32
• So, infection not recognized clinically though infectious agent is
passed out of human body & hence a person ē subclinical
infection is a greater health hazard for community
• Disease as Viral hepatitis A, have large number of subclinical
cases;
• But, disease as measles hardly have any subclinical infections.
• So, infections with many subclinical cases are less easily
prevented;
• But, disease with very few subclinical cases are more easily
prevented by surveillance methods.
Latent Infection
• when infectious “ r ” , without any
$$ but does not come out of human body.
After a period of time, under certain condition agent which was
lying dormant, may reactivates & produces a different type of
dis (e.g., Herpes Zoster; Brill - Zinser disease) or same type of dis
(e.g., TB reactivation).
Zoonoses
• Zoonoses = infections transmitted between vertebrate animals,
either directly, or indirectly by vehicle or insect
• Health important ones transmitted to man from vertebrate
animals, either directly, or indirectly through vehicle or vectors.
• called “anthro-pozoonoses” & include a long list of infections as
Rabies, Plague, Bovine TB, Salmonellosis, Japanese Encephalitis,
Scrub & Murine typhus, Echinococosis, Anthrax, Brucellosis & so
on.
• 2nd group are infections primarily infect man but can be
transmitted to animals; called zoo-anthro-ponoses.
• 3rd group is amphi-xenosis includes infections may be transmitted
from man to animals & vice versa.

33
• Opportunistic Infections = ← f , normally not
pathogenic, but ← ↓in general or specific immune status of host
turned pathogenic.
Term assumed greater importance following identification of HIV
infection whose $$ comprise of a wide variety of opportunistic
infections as P carinii, T gondii, CMV etc.
• Nosocomial Infection = dis contracted while in ←
care or related procedure.
• Such infections include those whose $$ may start after discharge
fr r “ ” ’
body at time of admission.
• Eradication = ‫ هام‬complete cessation of transmission of infectious
agent. Small pox is the only example where eradication achieved.
• Control =↓transmission, so, it is not PH problem. Control needs
ongoing preventive measures, & consequently continuing
expenditure, along ē efficient surveillance system to give early
warning of ↑in level of transmission.
Elimination: =
➢ either a ‘regional eradication” (say from a country or continent),
or of dis to zero without total removal of infectious agent from
environment.

34
 Epidemiologic “Chain” of Infection
4 related factors, referred “ f f ’
(a) infectious agent & its characteristics.
(b) human host who is susceptible to infectious agent, & various
factors which determine susceptibility.
(c) Characters of infectious process determined by interactions
between agent & host.
(d) “modes of transmission” of agent to host.
Let us discuss details of each of these components of chain of
infection.

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36
37
38
 Agent
3 broad groups of characters are imp of agent of infectious dis viz.
➢ Reservoir & immediate sources of agent;
➢ characters of agent connected ē its survival in environment; &
➢ characters of agent determining production of infection

39
40
• Causative agents of infectious diseases can be divided into four groups:
Prions are simplest infectious agents, consisting of single protein molecule. They contain no
nucleic acid & so no genetic information; their ability to propagate host relies on inducing
conversion of endogenous prion protein PrPc into abnormal protease-resistant isoform
referred to as PrPSc or PrPRes.
Viruses contain both protein & nucleic acid, & so carry genetic information for their own
reproduction. However, they lack apparatus to replicate autonomously, relying instead on
‘hijacking’ cellular machinery of host. They are small (usually <300nanometres (nm) in
diameter) & each virus possesses only one type of nucleic acid (either RNA or DNA).
• Bacteria are larger than viruses. They are enclosed by cell membrane & most have cell wall,
but some (e.g., Mycoplasma spp.) have only a cell membrane. This makes them resistant to
cell-wall-acting antibacterial agents (e.g., β-lactam antibiotics, including penicillin, &
glycopeptide antibiotics, as vancomycin).
Eukaryotes include unicellular protozoa, fungi (which can be unicellular or filamentous) &
multicellular parasitic worms. Other higher classes, as insects & arachnids, also contain
species that can envenom, injure or parasitize humans & cause disease.

41
 Reservoir & Immediate Source of Agent
Any infectious agent has a 1ry habitat, called “reservoir of
infectious agent” = “a person, animal, or inanimate environment
(like soil), where an infectious agent lives, & where it propagates
so it can be transmitted to a human host”
On the other hand, a source of infection is person, animal, or their
excretions or inanimate env from where infective form of agent is
available to susceptible human host.
➢ Take example of hookworm. Adult forms live in human gut,
depending on human for their survival. They multiply there, eggs
passed out & transmitted to another human, so propagate
species. Worms do not depend for survival & multiplication on
any other animal, soil, plants, etc. So, “reservoir of infection” is
“human infected ē Hookworm”, (human reservoir).
On the other hand, infection of another human being occurs ←
skin contact ē soil contaminated ē infective stage larvae. So,
“source” is “soil contaminated ē infective stage larvae”.
Types of “Reservoir of Infection
• Secondly, human reservoir may have subclinical or clinically
inapparent dis (contact or healthy carrier) e.g., Hepatitis A,
Cholera, Poliomyelitis, Diphtheria etc.
• A subclinical carrier should be differentiated from a subclinical
case, which refers to a person ē infection after IP but do not show
$$ & do not shed organisms, so infection not transmitted to
others; e.g., subclinical case of Japanese Encephalititis in which
f r , ē r, v r
inadequate to infect mosquito vector.

42
• Thirdly, person may continue to shed infectious agent, even after
recovery, during convalescence, so known as convalescent carrier
as in cholera, typhoid & bacillary dysentery.
• “ v rr r ” short term or temporary
carriers (lasts <4 weeks) or chronic carriers (lasts +4 weeks; may
be years as in chronic typhoid infection, of gall bladder.
• Animals & Other Forms of Reservoir: animals form another
reservoir, where infectious agent lives primarily, multiplies & is
available for being transmitted to human host.
• “zoonoses”
• Finally, some infectious agents like fungi may primarily thrive &
multiply in contaminated soil.

Characters of Agent Concerned ē Survival in Nature

Capability of agent to thrive outside reservoir & withstand
adverse env effects as drying, heat, acidity, etc is known as
“ rv v r ”
❑ Some agents can hardly survive outside human body (e.g.
measles, chicken pox).
❑ Others survive for limited time if conditions are favourable:
➢ e.g., cholera vibrio, polio virus, Hepatitis A, etc. can survive in
water, ice, sewage, milk, etc.;
➢ HIV can survive in bl & bl products;
➢ However, all of them are vulnerable to drying, heat &
disinfectants
➢ Finally, some organisms or their intermediate forms can
withstand adverse environment very well (e.g., clostridial spores,
cysts of intestinal protozoans, ova of helminths etc.)
➢ Usually, agents ē very poor survival in nature, have direct modes
of transmission as droplet infection or direct mucous contact.

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➢ Survival in nature becomes more crucial for agent, if human is the
only reservoir

Characters of Agent Producing Infection & Disease

Infectiousness = relative ease of agent transmission to host. It is
function of env factors; e.g., , ↑ over
crowdedness but ↓ r ← r
Infectivity f → f , , to enter, survive &
multiply in host.
✓ An epidemiologic measure of infectivity is Secondary Attack Rate
SAR
✓ Defined as number of susceptible persons who, during duration of
one IP, following exposure, develop dis /total exposed susceptibles
SAR measured by doing studies in closed community or families
where 1st case ē infection caused dis, it is called the index case.

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• Attack Rate (SAR). Pathogenicity is the ability of the agent to
produce manifest disease out of those who have been infected.
Virulence is the ability of the agent to produce severe disease.
The host factors which determine the dynamics of infection fall
into two broad categories - Host attributes which affect the
probability of being exposed to the infectious agent (like age, sex,
SES etc.) and host factors that influence occurrence
of infection and disease (like status of host immunity, genetic
make - up etc.). Herd immunity refers to the level of immunity
that is present in a population against an infectious agent.
Pathogenicity = f r ē $$ f
who were infected.
Agents ē ↑ , resist non - specific host defenses, &
produce toxins or similar products (e.g., Diphtheria, Tetanus) or,
may → host immune response → to dis (e.g., Rheumatic fever,
Glomerulonephritis).
• Virulence: more important than infectivity & pathogenicity. =
ability of agent to produce severe dis.
• f“ r ’ f r r f , Case Fatality
Ratio (CFR) is a good measure of virulence.
• Infective Dose: is imp in certain dis as V cholera & S typhi, so, if
inoculum is not adequate, infection will not settle
• or at least, manifest disease not occur.
On the other hand, in infections as plague, even very small dose
may be enough to cause infection.

45
 Host Factors
Host factors which determine dynamics of infection fall into 2
broad categories: a & b
(a) Host Attributes Affecting Probability of Exposure to Infectious
Agent: These include
age e.g., r ,← & habit of “orally
exploring” items, they are more susceptible to exposure to soil
transmitted helminthic infections
Sex e.g., females, by virtue of leading a mainly indoor life may be
< exposed to sylvatic zoonoses as rabies
Economic status poverty, squalor ‫ & قذارة‬infection form an almost
group
Occupation e.g. agriculture & veterinary workers are more
exposed to certain zoonoses
Education ↑k f & r v f f ,
↓ x r
Living conditions Poor housing, overcrowding, lack of sanitary
eating & drinking f ↑ f x r
Life style & behavioural factors e.g., permissive ‫ متسيب‬attitude
r x↑ r f x r r rv r f
use of Personal protective measures e.g., use of mosquito nets
r ↓ f x r q r
(b) Host Factors Influencing Occurrence of Infection & Dis:
➢ “ x ” f , r f r
determine dis occurrence & severity. These include:
➢ status of host immunity, whether actively or passively (or
naturally or artificially) acquired
➢ Age extremes of age viz. very young, i.e., < 2 y & old > 65 ys, >
susceptible.
➢ Genetic makeup known to occur in respect of dis as TB & malaria
46
➢ Availability & utilization of health services by providing
chemoprophylaxis, immunization & health ed at 1ry preventive
level, early diagnosis & prompt TTT

47
 Herd Immunity ‫إنما يأكل الذئب من الغنم القاصية‬
‫هام‬
➢ = immunity of population against an infectious agent.
➢ → r f fr f , r
presence of immune individuals.
➢ = “resistance of a group to dis, ē large % of immune persons → ↓
probability of person ē infectious agent, to transmit it, to another
susceptible person, in same population”.
➢ On childhood infectious dis prevented by IMZ, vac coverage of ⁓
85%, mostly provide adequate herd immunity → ff v block of
dis transmission, even if remaining 15% children are not
immunized
Herd Immunity‫التكرار يعلم الشطار‬
Herd immunity is important in infections spreading from person
to person.
Herd (or population) immunity = % of a population ē level of
immunity sufficient to protect individual from an infection.
The higher the herd immunity, the less likely an infective person
in population will infect another susceptible person, & continue
chain of infection. So, high herd immunity interrupts disease
transmission.
Other factors influence propagation of an infection include
intrinsic infectiousness of pathogen, mobility of cases during they
are infectious, duration of infectivity of each case & density of
population.
For a highly infectious dis as measles, herd immunity must be high
(over 95%) to prevent one or more generations of infection
resulting from each case.

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 For less readily transmissible infections, disease elimination &
even eradication (case of smallpox) may be achieved with a lower
level of herd immunity.

Herd Immunity‫التكرار يعلم الشطار‬

• Declining levels of herd immunity underlie phenomenon of
outbreaks of common infectious dis between periods of lower-
level endemic disease.
• In pre-vaccine era, many infectious diseases of childhood
affected majority of each birth cohort during 1 st ys of life.
Incidence of dis ← measles & rubella, & subclinical infection
caused by poliovirus, was high, & there were frequent
superimposed epidemics.
Today, we provide effective vaccines to most infants in 1st y of
life, so vaccine preventable dis are rare or absent. However, a
small proportion of each birth cohort will either not receive
vaccine or receive vaccine but not develop protective immunity.
• The numbers of such people who remain susceptible to infection
are small, & they are shielded from infection by herd immunity
of surrounding population.
• However, as years pass, susceptible % of population ↑to point
where introduced wild infection, can pass from one susceptible
person to another, & an outbreak may occur.
These outbreaks occur less often & affect fewer people than in
pre-vac era, but they may still cause damage & death.

49
50
 Example for herd immunity: measles transmission
If each case of measles can infect 15 susceptible individuals, then
to prevent increasing spread of the disease, at least 14 of every 15
people in the population need to be immune by immunization.
Therefore, the percentage of the population that needs to be immune
is 14/15 = 93%. Taking into account that about 10% of the population
may not develop adequate immunity to a single dose of vaccine, we will
need to immunize about 95% of the population with two doses of
vaccine to ensure adequate herd immunity levels.

Herd immunity is the concept that, an individual who is susceptible

to an infection, may still be protected against that infection, if sufficient
numbers of people in community are immune to it. The concept only
applies to infections transmitted solely by person-to person spread. The
proportion of population needing to be immune in order to confer
protection on the remaining susceptible individuals is referred to as the
herd immunity threshold. This depends on effective reproduction number
for relevant infection & achieved when each case of the infection is
transmitted to less than one other person. When this stage is reached, the
infection cannot be sustained in the community and
is eliminated. (fig below)

51
 Factors Affecting Process of Infection
as a Result of Interaction Between Agent & Host
There are certain features which are peculiar to each infectious
disease as follows
Incubation Period
✓ IP = period bet entry of infectious agent (or its toxin) into body till
earliest apparent $$
✓ During it, no $$, but immunological & histopathological changes in
body occur
✓ f, r P, r fr , =“ r
rr r”
✓ IP r “median IP”, , time in which ½ infected
subjects develop $$, after organism entry in body.
✓ Along ē median IP, “range” given.
✓ IP calculated by studying time taken for onset of secondary cases,
following exposure to index case, in family groups or in closed
communities, or
✓ r v f“ - vehicle, point source
”
✓ Different diseases have different values of median IP & range
& All physicians & students must remember them well.

Events that take place during IP ‫هام‬

After entering body pathogen circulates & reaches target organ,
where it
➢ lodges, gets adopted,
➢ multiplies &
➢ reaches an optimum number,
➢ v r ’ defense mechanism,
➢ disturbs structure & function of that organ,
52
➢ produces changes in body fluid & body tissues,
➢ disturbs health equilibrium &
➢ results in clinical $$ of dis
Factors influencing incubation period
These are:
➢ virulence of pathogens,
➢ infective dose
➢ susceptibility of individual
➢ In short, IP depends upon host-parasite relationship

Variability
Every infectious disease has IP. It varies from dis to dis & in same
dis it varies from person to person, depending upon the above
factors.
➢ Disease with very short IP (few hours to few days): For example,
food-poisoning, bacillary dysentery, gonorrhea, meningococcal
meningitis, cholera, etc.
➢ Dis ē IP from few days-few weeks (1-3 weeks). For example,
Chickenpox, common cold, chancroid, measles, mumps, malaria,
diphtheria, tetanus, pertussis, typhoid, poliomyelitis, yellow
fever, etc.
➢ Dis ē IP from few weeks-few months: For example, Amoebiasis,
hepatitis A and B, kala-azar, rabies, etc.
Dis ē IP from few months to few years: For example,
Tuberculosis, leprosy, filariasis, AIDS, dracontiasis, etc.
Communicability during IP:
➢ It is capacity of an infectious agent to spread to others.
➢ Usually, infectious diseases are not communicable during IP
➢ Exceptions are chickenpox, diphtheria, pertussis, poliomyelitis,
measles, mumps, hepatitis A.

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➢ Such persons who are spreading disease during IP are called
‘ r carriers”.

Uses of IP ‫هام‬
1. Helps in making diagnosis: Short IP helps in making diagnosis,
as in food poisoning, gonorrhea, donovanosis, etc.
2. Helps to trace contacts or source of infection: As in dis ē short
IP. This is not possible if IP is long. Tracing source of infection or
contacts helps to implement control measures.
3. For quarantine purposes: ‫ الحجر الصحي‬Quarantine = limiting
movement of healthy persons, who are suspected to be exposed
to a communicable dis, for period = to longest IP of disease.
This used to prevent international spread of dis as smallpox,
cholera, plague & yellow fever by, quarantining travelers
vaccinated in international airports & seaports.
4. For imz purposes: at-risk person protected by immunizing after
exposure to dis by making use of long IP as in rabies, tetanus, etc.

54
55
Latent Period: In infectious dis epidemiology, latent period =
time between entry of agent into body till point when shedding of
organism starts.
Period of Communicability (Infectious Period) = duration during
which host sheds agent, i.e remains infectious. It may be very long
in case of leprosy & HIV.
Generation Time = duration bet entry of infectious agent into
body to peak infectivity of host. As a crude calculation, generation
time (G) = (latent period + period of maximum communicability).

56
 Biological Gradient (Gradient of Infection)
➢ Biological gradient of a dis = range of $$ that may occur in host←
infection.
➢ k “ r ”, r fr r f
end, & passing through mild illness, clinical dis, serious forms of
dis, to death at other extreme of spectrum.
Diseases like viral Hepatitis - A, poliomyelitis & cholera have a
classically wide biological gradient ē all varieties of severity as
outlined above being present.
➢ On other hand, measles & chicken pox tend to have only middle
part of spectrum ē either subclinical cases or deaths being
uncommon.
➢ Diseases like rabies occupy only other extreme of spectrum,
having a very serious biological gradient, ē certain death being
only outcome.

Frequency of Disease
➢ Epidemiology observes number of cases of a dis & convert it into a
frequency measure (incidence or prevalence) by relating number
of cases to a denominator (population at risk).
“fr q ” f , occurrence may be
● “Epidemic” = rr f fr q , f
population or area, which is in excess of regular expectation.
● “Sporadic” = few, scattered cases of infection, which do not
have any relation to each other according to place or time
➢ In a low endemic dis, frequency of dis is low but cases would show
a relation to each other according to place or time

57
➢ “Endemic” = continued transmission of a disease, in a defined
population or area, at a relatively low level, ēout any importation
from an outside area or population
➢ Difference bet epidemic & endemic is, high frequency & “abrupt
↑ occurrence in epidemic situation, compared to “continued
transmission” in endemic case.
➢ In both hyperendemic & holoendemic, transmission continues at
a very high frequency; however, in holoendemic, exposure to
infection occurs during early childhood so by adulthood,
population becomes immune & a high level of herd immunity
occurs. For this reason, epidemic outbreaks of dis are not likely in
holoendemic situations (classical example be “ r ”)

Channels of Transmission
• 2 end points in epidemiological chain of infection are infectious
agent & (susceptible) host.
• To complete this link, infectious agent must be transmitted to a
host.
Such link bet agent & host is of 2 type , v z “ r ” & r ”
modes of transmission.

58
59
60
(a) Direct Modes of Transmission
direct transmission when agent in actual proximity ‫ قرب‬ē host, or
very close distance. There are 4 methods of direct transmission
● Contact of host skin or mu mem ē infectious agent contained in
a living tissue; e.g. STDs
● Contact of skin or muc mem ē infective form of agent contained
in inanimate env. Examples: transmission of hookworm (infective
form in soil) & leptospirosis: infective form in water or soil
contaminated ē urine
● Inoculation of agent, directly from reservoir into skin or mucous
as in Rabies.
● “Vertical transmission” fr r , r ,
e.g., , ,“ ”

61
62
Direct transmission ← close distance of host, “droplet
infection”
• Droplets are very finely dispersed aerosol containing infectious
agent, formed when a person harbouring agent in resp tract
coughing, sneezing, talking etc.
• If another host is at close distance (usually 1 meter or less),
infective droplets directly deposited on mucous membrane of oral
cavity or resp passage (i.e. relevant portal of resp tract infections).
Examples: TB, common cold, influenza, measles, mumps,
pertussis, diphtheria, meningococcal infection, leprosy etc.

(b) Indirect Modes of Transmission:

= f r q r “ r r ” v
from source of infection to susceptible host. Types of indirect
modes of transmission:
Vehicle Borne f “v ” v f
include anything eaten (e.g., food, sweets) & so on, or anything
drunk (e.g., milk, water).
Infections of GIT transmitted so. include cholera, typhoid,
hepatitis - A, ascariasis, amoebiasis & many others.
A vehicle, also include anything “injected” (e.g., bl & bl products,
drugs, vaccines, examples are HIV, Hepatitis B, Malaria etc.).
• “Fomites” = inanimate objects of general use by infected person
(e.g. utensils, linen, pens, tooth brushes etc.)
Infectious agent may remain on surface of such fomites & may be
transmitted to host when such objects are put into mouth or
come in contact ē conjunctiva.
Fingers: Fingers form a very important mode of indirect
transmission. If Contaminated, they can transport a number of

63
 GIT infection (especially, shigella, Salmonella typhi, vibrio &
Entamoeba).
• Air: droplets containing infectious agent may dry, or may settle
down on dust.
• If agent survive env as drying or heat, it can be carried for long
distances by air currents, along ē dust or droplet nuclei; & if
r f r f , → infection.
Some examples are legionnaires dis, ‘Q’ fever, tuberculosis,
nosocomial infections.
• Air borne infected nuclei & dust should be differentiated from
“ r f ” ‫هام‬
• As explained, droplet method is a ‘direct” method of
transmission in which agent is directly deposited from
immediate source of infection onto portal of entry of a
susceptible host, intervening distance being very short
(maximum 1 meter).
• While, in air borne transmission agent is not directly deposited
from source of infection on to the portal of entry of host but
transported indirectly by air over long distances.
Vector Borne Indirect Transmission:
• A vector is a living invertebrate which transfers infectious agent,
from source of infection, to another susceptible host. Mainly
arthropods, & to a smaller extent, snails.
• This transmission, firstly, can be either “mechanical”, where
vector transferring infectious agent mechanically from host to
vehicle as food, by carrying agent on its surface or in gut (finally
excreting them in faeces).
• As housefly, which mechanically transmits a number of
orofecal dis agents, from faeces to food.

64
• Also, it CAN be a “biological” transmission, where agent
transmitted, undergoes, in vector, one or more of biological
changes as a stage in its life cycle.
• Such changes may occur in one of following 3 ways:
● x f plague bacillus taken by rat flea following a bl meal
on rodent, bacilli multiply & ↑in number, in mouth parts of rat
flea.
f “ ”, “ v ”
in body of vector known as “propagative” mode.
• If agent developed inside vector but no multiplication, known as
“cyclo developmental” female culex mosquito
takes microfilaria ē bl meal. 3 larval stages end by infective stage
larva
● , f r f r &f ℮
blood meal by a mosquito. Gametocytes → gametes → zygote →
oocyst & sporozoites. So, there are developmental changes in life
cycle of agent. Also, for 1 male & female gametocyte taken by
mosquito, 1000s of sporozoites formed. So, developmental
changes & multiplication r, k “cyclo - propogative”
• Ophthalmic Route
A common route of virus introduction into the body is through the
eye by touching dirty fingers, using contaminated swimming
pools, from non-sterilized ophthalmic articles or even aerosol
droplets.
• Milk-Borne Route
A number of viruses that are secreted in milk are transmitted to
new born infants. There is also an added risk of introduction of an
infectious agent to the infant while breastfeeding from an
infected mother. Although, chances of this is a lot less than the
risk of vertical transmission of an infection while childbirth. In

65
 countries and communities where malnutrition or infectious
diseases are a common cause of infant mortality, breastfeeding
may still be prescribed despite the added risk of transmission that
it poses.
• Nosocomial Infections
• efinition: infections acquired >48 h after admission to a
healthcare facility OR within 30 d from discharge
• isk factors: prolonged hospital stay, antibiotic use, surgery,
hemodialysis, intensive care, colonization with a resistant
organism, immunodeciency
■ patients with nosocomial infections have higher mortality,
longer hospital stays, and higher healthcare costs
• Hand hygiene is an essential precaution

66
67
68
 Outbreak
Definition: An outbreak can be defined as:
• r r x r r illness or confirmed
infection, and are linked by a common factor, or • W rv
number of cases unaccountably exceeds expected number for a given
place and time. The term can be used to describe a range of situations
from local outbreaks of food poisoning to international epidemics. The
terms epidemic &outbreak used interchangeably.
Management: Procedures include:
• fr f r k( r r
artefact)
• f f v r , r and mode of
transmission
• v f r f • rr r r v f
transmission
• r r v r
• r r r r f
policy and practice.
Factors that influence management include:
• r f , f -free area •
Number of cases, e.g. diarrhoea and vomiting affecting a large school
• f r , r r ,
community
• d widely available product implicated, e.g.
cryptosporidium in public water supply. First, the problem should be
confirmed & diagnosis verified. Control measures may have to be
instigated immediately to stop further transmission based on the initial
available information, as preventing further cases of disease takes
precedence over investigating the cause or source.
69
 • The initial epidemiological approach involves active case finding,
as the initial cases discovered may only be the most severely
affected.
• A clear case definition is required. Data are then collected usually
using standard questionnaires to generate an initial hypothesis.
This descriptive epidemiology allows us to describe cases by time,
place and person.
• Plotting an epidemic curve, a frequency distribution of date of
onset, may identify an incubation period which, combined with
clinical features, can help identify the potential cause and source
of spread: e.g., point source, continuous source, person-to-person
spread.
The initial hypothesis can then be tested or confirmed by
conducting analytical epidemiological studies, usually a case-
control or cohort study, which may involve further microbiological
or environmental tests.
Further control measures may then be necessary. Surveillance is
necessary to determine when the outbreak control team can declare
the outbreak over, using agreed preset criteria. Finally, any lessons
identified should be used to help prevent future outbreaks.
• Several viruses continuously flow amongst animals, mostly birds.
Although these viruses are capable of causing viral outbreaks
theoretically, but in
• Phase 1 of an outbreak there are no reported human infections
caused by these viruses circulating amongst animals (Fig. coming).
In Phase 2, there is a potential epidemic threat from an animal
virus circulating among domesticated or wild animals which has
caused an infection in humans.

70
In Phase 3, although still no human-to-human transmission
enough to sustain community-level outbreaks established but
even so, an animal or human animal virus has caused sporadic
cases or small clusters of disease in people. However, in case of
close contact between an infected person and an unprotected
caregiver there may occur limited human-to-human transmission.
The transmission under such constricted circumstances does not
show that the virus has gained a level of transmissibility among
humans required to cause an epidemic.
The Phase 4 is said to begin once community- level outbreaks of
human-to human transmission of an animal or human-animal
virus verified. A substantial increase in risk of causing a pandemic
is marked by potential of a virus to cause perpetual disease
outbreaks in community. WHO should immediately be consulted
if any country verified or suspects an episode so circumstances
may be assessed together & decision can be sought by the
country affected to implement a quick containment operation?
While this phase stipulates a noteworthy hike in risk of a
pandemic it surely does not mean that a pandemic is certain in
the future.
Phase 5 is finally where virus has spread via human-to-human
route in at least two countries of one WHO region. Although
majority of the countries would not be affected at this time, the
announcement of Phase 5 is a powerful indicator that a pandemic
is absolute & there is just a short time to work out the
organization, communication, and implementation strategy of the
planned mitigation measures.

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72
Epidemiological surveillance ‫هام‬
purpose of surveillance
• v r v r
• r f r k
• r f f
• r cidence
• r k r kf r
• v f r r
• f alth policy
steps of surveillance
• f
• f v r f r
• f r
• f
• r r f f r
• action
• rv

73
• Definition
Surveillance has been defined as the continuing scrutiny of all
aspects of the occurrence and spread of a disease that are
pertinent to effective control. It involves a systematic collection,
collation and analysis of data and the prompt dissemination of the
resulting information to those who need to know so that action
can result. Although this chapter focuses on surveillance of
communicable diseases, the principles apply similarly to non-
communicable diseases including cancers.
Sources of data for surveillance
In every country, there is a statutory requirement for certain
infectious diseases to be notified by registered medical
74
 practitioners to public authorities. Legislation revised recently to
provide public authorities with new powers & duties to prevent
and control risks to human health. In addition to the list of
infectious diseases, the new regulations require clinicians to notify
public health authorities of cases of other infections or
contamination (including chemical or radiation) that could
potentially be a significant risk to human health.
Data on sexually transmitted infections is usually obtained from
genitourinary medicine clinics. International surveillance data is
obtained from WHO.
Principles of surveillance
The basic principles of surveillance are listed in Figure 25a. An
ideal surveillance system needs to be:
•
• Pr
The case definition in the initial stages necessarily has to be sensitive,
so that all possible cases are recognized and measures can be put to
place to try and control the spread of the infection. The case definition
will usually consist of a combination of clinical features and
epidemiological features. The epidemiological component will relate to
symptoms occurring within the incubation period after returning from
an affected area. It can also relate to onset of symptoms within the
incubation period in a close contact of a known case.
While the early recognition of cases can help to prevent spread, it is
important during the early stages that the diagnosis is confirmed using
specific microbiological tests. The surveillance system needs to be
designed to enable necessary actions, which include:
• r r f ( r v r r )
• rr f r r
workers and household members by appropriate measures

75
• f f r r r f vr
and its spread.
The surveillance system needs to consider collecting data from a
number of sources including clinicians, laboratories and additional
sources such as schools, pharmacies and ports of entry. It is essential
that the case definition is widely disseminated and reporting
mechanisms are quick, easy and practical to ensure good response
rates.
Once the infection becomes well established, it may be appropriate to
stop or change special surveillance systems based on clinical or public
health need. However effective action based on the development of an
active surveillance system initially helps to delay the potential spread
and allows time for the development of a vaccine.

76
77
78
General prevention &
control measures
Preventive medicine, PH, by definition
• Preventive medicine seeks to enhance lives of individuals by
helping them improve their own health,
• Whereas public health attempts to promote health in
populations through application of organized community efforts.
• aim of epidemiological efforts are to prevent & control entry &
spread of diseases in communities
disease prevention & control depends upon knowledge of: its aetiology,
epidemiology, mode of infection, route & mode of transmission of
aetiological agent, TTT, natural history disease

79
80
81
 Natural history of disease ‫هام‬
➢ pre pathogenesis phase (pre disease phase),
➢ pathogenesis phase (latent & symptomatic dis stage) &
➢ post pathogenesis phase.
pre disease stage: individual factors promote or resist dis including:
genes, age, env exposures, nutrition, social environment, immunity &
behaviour

Disease classes:
To help in prevention & control, we classify disease according to mode
of transmission, as follows:
(a) Contact transmission - direct & indirect.
(b) Vehicle transmission - water, food, milk etc.
(c) Vector transmission - by arthropods.
(d) Air-borne transmission - droplet, droplet nuclei & infected dust.
(e) Animal-borne transmission - zoonoses
(f) Trans placental transmission or vertical
Common Gestational Periods for Vertical Transmission of Diseases:
Congenital Varicella: First trimester
• Congenital Rubella: First trimester
• Congenital Parvovirus: Second Trimester
• Congenital Syphilis: Third trimester
• Congenital Toxoplasmosis: Third trimester
• Congenital Hepatitis B: Third trimester
• Congenital CMV: Third trimester
• Congenital HIV: During delivery
• Congenital Hepatitis C: During delivery
• Congenital Herpes: During delivery

82
 Control Measures
• Control of Reservoir & Source of Infection: first link in chain of
infection is infected persons, cases (clinical or subclinical) or
carriers, = primary source of infection.

General measures to control of reservoir of infection:

(a) Early detection of cases.
(b) Notification
(c) Isolation
(d) Treatment.
(e) Quarantine.
(f) Surveillance.
(g) Disinfection.
Block channels of Transmission:
• Achieved by general environmental control,
• Env sanitation: safe water supply, sanitary disposal of sewage &
waste, food hygiene, vector control, personal hygiene, proper
ventilation, prevention of overcrowding & dust control
• Protection of Susceptible Population: DONE by
➢ immunization,
➢ chemoprophylaxis,
good nutrition, health education & personal protection.

83
After Occurrence of an Infectious Disease:
(a) Early detection of case.
(b) Isolation of case for period of infectivity.
(c) Prompt & effective TTT of case.
(d) Disinfection of discharges & fomites.
(e) Notification.
(f) Surveillance of contacts.
(g) Mass immz of vulnerable GROUPS.
(h) Investigation of current outbreak.
(i) Survey to assess endemicity.

Chemoprophylaxis ‫هام‬
• = prevention of infection or its progression to clinically manifest
dis by administration of chemical substances, including
antibiotics.
• Use of antibiotics before surgical procedures is an example of
non - specific Chemoprophylaxis to prevent wound infections in
postoperative period.
• Examples of specific Chemoprophylaxis are as follows:
• Using chloroquine to prevent malaria parasitaemia
use of silver nitrate, erythromycin or tetracycline instilled into eyes
of a newborn to prevent gonococcal ophthalmia ← r ission of
Neisseria gonorrhoeae from an infected mother during birth.
● f tetracycline, sulfonamides or streptomycin in close
contacts of confirmed or suspected cases of plague pneumonia to
prevent plague.

84
● f Rifampicin in close contacts of meningococcal meningitis
patient.

Chemoprophylaxis to prevent progression of an infection to

active manifest disease:
Use of co - trimoxazole or pentamidine to prevent subclinical latent
f ē Pneumocystis carinii from progression to cl manifested
pneumocystis pneumonia in immunosuppressed persons as HlV -
infected individuals.
● f r - sulfadiazine - folinic acid to prevent
asymptomatic infants congenitally infected ē Toxoplasma gondii
from being clinically manifest chorioretinitis & other sequelae of
congenital toxoplasmosis.

Chemoprophylaxis to treat an infectious disease to prevent

complications of disease:
Penicillin to treat streptococcal sore throats ← Streptococcus
pyogenes group A, to prevent acute rheumatic fever.
● Benzathine penicillin for treatment of syphilis in its 1ry, 2ry, or
early latency period, to prevent late manifestations of dis as
cardiovascular syphilis.

85
86
87
88
 Disinfection
General Recommendations (done for ANYTHING RELATED TO
PATIENT)
To summarize, disinfection of following, must done for all cases of
infectious illness:
( ) ’ x r & r , , & r r
used by patient.
(b) area occupied by pt before removal to hospital & their contents.
(c) vehicle in which pt is conveyed to hospital.
(d) On recovery of patient, ward/ room in which pt was treated & its
contents.
(e) In case of carriers or contacts disinfection should be done at
place of care, of physician in medical charge
Definitions:
(a) Disinfection = destruction of specific microorganisms →
communicable dis, outside body.
(b) Disinfectants = agents used for disinfection.
(c) Antiseptics = , ↓ r & f
microorganisms, but are not strong enough to destroy them
completely. A sufficiently diluted or weakened disinfectant
becomes an antiseptic.
(d) Disinfestations = destruction of undesirable animal forms,
especially arthropod ectoparasites present upon persons or on
domestic animals. In practice refers to destruction of
ectoparasites like lice, sarcoptes, bugs & fleas & their ova & eggs.
(e) Disinfestants = agents used for disinfestation. Disinfestants
a r = r ‘ r f
disinfectants are disinfestants if used in adequate strength, but

89
all disinfestants or insecticides are not disinfectants.
(f) Detergents = surface cleansers & degreasers. They dissolve
grease & oily matter & so help removal of dirt etc., from any
material when rinsed or washed with water consequently
removing the micro - organisms sheltered by grease & dirt.
(g) Deodorants: = substances, which mask unpleasant odors
without having disinfecting or antiseptic powers. Many
disinfectants & antiseptics mask putrefactive odours also.
Objective
The objective of these processes is to cut links in chain of spread
of communicable diseases
Classification of Disinfecting Agents
Disinfecting agents can be classified as follows:
(a) Natural Agents
● r r
●
(b) Physical Agents
● r r ; r r; - ironing
● ( r without chemical agent); Steaming
- current steam & steam under Pressure.
● z r ; r v r
(c) Chemical Agents
●
● q
●G
● r

90
 Disinfection Procedures:
• Concurrent Disinfection =disinfection of pt, of his excreta &
discharges & of all articles, used by him, or likely to be
contaminated during course of his illness, including hands &
clothing of attendants.
Terminal Disinfection =disinfection of room or premises & their
contents after patient recovered, died or removed elsewhere. It
includes vehicle or ambulance, wheel chairs & stretcher used by
r‘ ’ r‘ ’
(i) Local =disinfection of bedding & bedsheet occupied by pt,
walls, floor, furniture including kit box, shelf, lockers & their
contents & all other surfaces or articles ēin 2 meters around bed.
(ii) Complete= disinfection of the whole room & all its contents.
Prophylactic Disinfection = chemical TTT or boiling of water,
pasteurization of milk, washing of hands & so on
Classification of Disinfecting Agents:
Disinfecting agents can be classified as follows:
(a) Natural Agents
● r r
●
(b) Physical Agents
● r r ; r r; - ironing
● ( r );
- current steam & steam under Pressure.
● z r ; r v r
(c) Chemical Agents
●
● q
●G
● r

91
 INVESTIGATION OF AN EPIDEMIC DISEASE
imp 19-‫تخيل ما حدث و يحدث لحاالت كوفيد‬
Importance:
▪ Whenever an outbreak of a dis occurs in a community affecting
large number of people,
it becomes a public health emergency & calls for a thorough
investigation & implementation of control measures.
Objectives:
objectives of epidemiological investigations are:
• k distribution of outbreak in community ē reference to
time, place & person including environmental conditions
• k magnitude of problem in terms of morbidity &
mortality
• identify causative agent, source of infection, mode of
transmission
• control measures
• v recommendations for prevention of future recurrences
of epidemic.
Steps of INVESTIGATION OF AN EPIDEMIC DISEASE:
• Confirmation of presence of an epidemic
• Confirmation of diagnosis
• Collection of other relevant, ecological information
• Studying distribution of epidemic
• Formulation of etiological hypothesis
• Testing of hypothesis i.e., how did it happen?
• Implementation of control measures
• Submission of report
Steps explained:
1. Confirmation of epidemic: it is necessary to verify & confirm
existence of epidemic by:
92
➢ observing large number of people affected simultaneously ē
similarity of $$ &
➢ also, by comparing dis frequencies during same period of
previous ys. Comparison is not necessary in common source
epidemic e.g. acute gastroenteritis, food poisoning. Meanwhile,
baseline epidemiological data is collected as name of village,
primary health center, district, total population of area,
availability of health services, date of visit & names of
investigating officers.
2. Confirmation of diagnosis: done from history & $$ of a sample
of cases. Necessary material e.g., bl. & urine is sent for lab
investigations.

• 3. Collection of other relevant, ecological information:

as sex affected female or male, season, atmospheric temp &
humidity, which often favor onset of an epidemic.
4. Studying distribution of epidemic ē reference to time, place &
person.
a. Time distribution of epidemic by plotting number of cases
against dates on a graph, curve obtained called ‘Epidemic curve’
& shape of curve helps to know type of epidemic (Fig. A).

93
b. Place distribution of epidemic studied by plotting number of
‘ ’ r‘ r ’ēr r
area map. This is called ‘Geographical spot/shaded map’
(Fig. B). The pictorial presentation shows at a glance, area of high
& low density. area of high density gives a clue about source of
infection & even mode of spread. This is how John Snow was able
to focus attention on particular water

94
Fig. B: geographical
distribution
7. Formulation of etiological hypothesis: to identify diag.,
causative agent, possible source of infection, mode of spread,
environmental factors ↑occurrence of epidemic.
r x , r k f r r → Vibrio eltor
organisms, transmitted from river/well, through water.
8. Testing of hypothesis: ‘ - r ’
calculate exposure rate.
If exposure rate is more among cases than among controls, then
there is an association bet suspected factor & disease.

95
9. Implementation of control measures: done at beginning of
epidemic, on basis of known facts of dis. After detail
investigations, measures modified, for better control of epidemic.
10. Submission of report: should be systematic, correct,
comprehensive, complete including: recommendations for prev
recurrence of epidemic.
The area is declared free of epidemic when twice IP lapsed from
the date of detection/death of the last case.

96
 PREVENTION & CONTROL
OF AN EPIDEMIC DISEASE ‫هام‬
• basic concept of control of an outbreak of disease is to break
weakest link in chain of transmission of disease. Through 3 major
steps:
1. Elimination of reservoir
2. Breaking channel of transmission
3. Protection of susceptible.
Elimination of Reservoir:
Elimination of environmental reservoir, as air, water, soil, etc. is
unfeasible & out of question.
• Elimination of animal reservoir = keeping animals away from
human habitation & is possible but difficult.
For example, pigs in outbreak of Japanese encephalitis & cattle in
brucellosis.
• Elimination of human reservoir = eliminated from acting as a
source or reservoir of infection by following measures, i.e.
infectious person is made noninfectious.

infectious person is made noninfectious:

• Early diagnosis
• Notification
• Epidemiologic investigation
• Isolation
• Disinfection
• TTT
• i. Early diagnosis: Earlier diagnosis is made & earlier TTT started,
so further transmission can be prevented. Delay in making
diagnosis → spread of dis. It is said that early diagnosis & prompt
TTT of a case or carrier is ‫وأد الفتنة في مهدها‬.
97
• Also helps to know source of infection, so they are traced & TTT
as in STDs, food poisoning, etc.
ii. Notification = official report to local health authority, so they
rush to spot & begin control measures early, to prevent further
spread.
iii. Epidemiologic investigations: A detail epidemiologic
investigations will be done in area:
• k r f ē reference to time, place & person
• k causative agent, source of infection, mode of
transmission, factors influencing
• k magnitude of problem by estimating attack rate &
case fatality rate.
• iv. Isolation = separation of sick person from others, in isolation
ward of hospital, for a period of time, till he becomes
noninfectious, to prevent further transmission to others.
• This P r ‘ ’ , r
remains confined to pt & it is not transmitted to others.
This is of important value in highly infectious dis like diphtheria,
pneumonic plague, SARS, pertussis. etc. where risk of
transmission is very high.
It is of limited value in dis where large number of subclinical &
carrier state occurs, as in typhoid, viral hepatitis A, etc.
If isolation is of no value in control of dis like TB, leprosy, etc.
which carry social stigma. So, it is replaced by chemical isolation,
i.e., giving domiciliary treatment.
v ‘Ring immunization’, , encircling
infected person/house ē a barrier of immunized persons, so dis
does not spread. This was practiced to eradicate Smallpox & now
practiced in US to eradicate measles.

98
• v. Disinfection (Concurrent disinfection) = disinfection of body
discharges as sputum, urine, & stools of pt. It is done as long as pt
is in isolation ward.
Terminal disinfection = disinfection of left-over articles of pt, after
death or discharge of patient.
vi. Treatment: done ē objective of killing disease agent when it is
still in reservoir, so infectious person becomes noninfectious.
‘ v ’
• In high endemic areas, entire population given TTT ē drug
irrespective of whether they have disease or not, as in malaria,
f r ‘Mass TTT’, r f r f
members, as in scabies.
• vii. Quarantine = ‘ of freedom of movement of healthy
persons, suspected to be exposed to a communicable dis for a
period = longest IP of dis, in international airport or seaport, to
preven r r f ’
• That means those who were not having g valid certificate of vac
were quarantined. It was practiced against smallpox, plague,
r & f v r ‘Absolute quarantine’
‘Modified quarantine’ (partial quarantine) is selective limitation
of freedom of movement. For example, exclusion of children from
going to school during period of TTT, as in scabies, diphtheria,
chickenpox, etc.
‘Segregation’ r f r f
susceptible persons to protect them from getting a dis from
infected persons, so controlling dis.
For example, placing susceptible children in homes of immune
persons.

99
Breaking of Channel of Transmission
a. Direct modes of transmission can be broken as follows:
• Contact Transmission broken by avoiding close, physical, skin to
skin contact ē infectious cases
• Droplet infection transmission broken by advising reservoir
(suffering from resp dis) to cover nose & mouth, while coughing,
laughing, sneezing & talking
• Soil borne transmission prevented by using shoes while walking
• Bite by animal prevented by being away from them
• Transplacental transmission (perinatal or vertical transmission)
broken either by giving TTT to mother during pregnancy as in
syphilis or by terminating pregnancy as in rubella.
Prevention of parent to child transmission (PPTCT) in HIV +ve
pregnant mothers is done by giving zidovidine or nevirepine during
r rē f r r v f vr
to newborn. Efficacy is 40%
b. Indirect modes of transmission can be broken as follows:
• Vehicle route broken ACCORDING TO vehicle:
Water to be chlorinated, milk to be pasteurized, blood to be
screened, fruits & vegetables to be disinfected, & DOING food
hygienic measures.
• Vector route broken by control of vectors.
• Air-borne transmission prevented by controlling air pollution,
control of infected dust in hospital wards & other measures as
adequate ventilation, etc.
• fomites transmission prevented by disinfection of fomites.
• contaminated hands & fingers transmission prevented by
adopting personal hygiene e.g. hand wash.

100
Protection of Susceptible
Susceptible protected by 2 measures:
1. Specific measures as immunoprophylaxis, chemoprophylaxis.
2. General measures as improvement in quality of life (as good
housing, better nutrition, environmental sanitation, etc) & legislation
of laws.

101
 Immunization
The immune system
Structure & Function of Immune System
Tissues & organs important for immune function include:
● r v from stem cells: liver, bone marrow
● stored, multiply, interact & mature in:
thymus, spleen, lymph nodes, blood
● r r v
● r r x, ,
immune system protects humans from infection ē layered
defenses of ↑ specificity.
1st physical barriers prevent pathogens as bacteria & viruses from
entering body
If a pathogen pass these barriers, innate immune system provides
an immediate, but non-specific response. However, if pathogens
avoid innate response, 3 rd layer:
adaptive immune system, system adapts response to infection, to
improve its recognition of pathogen. This recognition retained
after pathogen eliminated, in form of an immunological memory,
& allows adaptive immune system to deal faster & better each
time this pathogen is encountered

102
103
Antigen (Ag)
➢ Antigen= substance on entering body, stimulates
production of specific abs & combines specifically ē
this Ag
➢ best antigens are proteins (e.g., diphtheria toxin,
tetanus toxin); others are polysaccharides e.g., bl
group antigens, lipids & nucleic acids.
➢ There are incomplete antigens ‘haptens’
Alone they are not antigenic but can provoke an
immune response by combining ē one of body’s
proteins , r ‘f r ’
Penicillin is ‘hapten’.
On contact ē antigen host respond in 3 ways:
(a) Circulating ab formed. (b) delayed-type cell
mediated hypersensitivity reaction result on 2nd
contact ē antigen
(c) Tolerance= on second contact ē same antigen no
response will be provoked.
Type of response in Each case depend on:
➢ antigen itself,
➢ dosage, &
➢ route of application
104
105
Antibody
➢ Antibody= protein produced by body ← invasion of
antigen
➢ Can react specifically ē → r
➢ Sites of max ab formation: lymph nodes & spleen.
➢ Smaller collections of ab producing cells widely
scattered in various tissues in body.
➢ Plasma cells also produce antibodies.
Ab may be antitoxic as diphtheria & tetanus,
antibacterial like typhoid or antiviral as polio.
Immunoglobulins (Ig)
➢ These comprise of families of closely related
globulins synthesized by cells of reticulo-endothelial
system (RES).
➢ human Ig system is divided into 5 major classes IgG,
IgA, IgM, IgD & IgE. ‫جامد‬
molecule of each Ig consists of K (Kappa) & L (Lamda)
polypeptide chain
➢ (a) IgG x r →
in serum ⁓ 80% of serum ab in adult

106
 ➢ Abs to gram+ve pyogenic bacteria, antiviral &
antitoxic antibodies found exclusively among IgG
globulins. IgG cross placenta.
➢ Maternally derived IgG, is slowly replaced by actively
synthesized IgG. These appears 1-3 months of age &
r ↑&
➢ adult level reached by age of 1-2Ys.
Normal adult serum level of IgG, is 600-1800 mg/100 ml.
(b) IgA: it contains isohaemagglutinins, anti-brucella,
anti-diphtheria antibodies = ⁓10% of serum abs.
Saliva, colostrum & tears are relatively rich in this
fraction
✓ Nasal & bronchial secretions, bile, intestinal juices
& prostatic fluid also contain IgA.
✓ It plays a decisive role in local immunity.
✓ IgA synthesis begins 2 weeks after birth.
Normal adult serum level, is 70-380 mg/100 ml.
✓ (c) IgM: have high agglutinating & complement
fixation ability.
✓ Wasserman antibodies & bactericidal ab against
Gram –ve organisms (endotoxins) found in IgM.

107
✓ It = 5-10% of serum antibodies.
✓ It cannot pass through placenta.
✓ Normal adult serum level is 20-130 mg/100 ml.
✓ (d) IgD: Not much is known about it.
✓ Normal adult serum level is 4-40 mg/100 ml.
(e) IgE: it has ability to fix themselves, firmly to
tissues, remain so. They are likely to play an imp
role, in allergic reactions.

108
 Immunity
defined as “Ability of an organism, to recognize, &
defend itself against specific pathogens or antigens

109
110
Types of immune response ‫هام‬
first action ē antigen is known as 1ry response. Reaction
ē same antigen causes A 2ry response that is more rapid
& powerful (later Fig.). Immune response depends on:
● r & f
● f r
● f j v
● r fr

111
Immune Response to Vaccination-important
❑vaccine mimics infection, ē pathogen, but ēout risk
of dis.
❑Consequent immune response, manifested by, ab
(humoral immunity) or cell mediated immunity
(CMI), or both.
❑Maternal CMI not transferred to foetus. This is why,
BCG given at birth. OPV given by mouth; ←
establishes local infection in a proportion of
children.
❑Hepatitis B vac, is excellent immunogen,
overcoming, inhibiting effect of maternal antibody;
hence it can be given at birth.
❑But live measles vac inhibited in presence of
maternal ab in f ’ r , v
after a delay of 9 m from birth & MMR given only
after 12 m.
❑goal of all vaccines is to promote a 1ry immune
reaction f r →
stronger 2ry immune response will be elicited. imp
❑Any subsequent immune response to an ag called
2ry response & it HAS following features:

112
 a) shorter lag time
b) More rapid buildup
c) higher overall level of response
d) more specific or better response to invading ag
e) Utilizes IgG instead of large multipurpose antibody
IgM
Types of vaccines
Traditionally, 4 types of vaccines (coming Table).
● v ( )
● v (k )
● x
● &r

113
114
115
116
117
 FUTURE TRENDS IN VACCINES
Although most vaccines developed in the twentieth
century targeted common acute infectious diseases
of childhood, more recently developed vaccines
prevent chronic conditions prevalent among adults.
Hepatitis B vaccine prevents hepatitis B–related
cirrhosis and hepatocellular carcinoma,
zoster vaccine prevents shingles and postherpetic
neuralgia, and HPV vaccine prevents some types of
cervical cancer as well as genital warts and
anogenital cancers.
New targets of vaccine development and research
may further broaden the definition of vaccine-
preventable disease.
Research is ongoing on vaccines to prevent insulin-
dependent diabetes mellitus, nicotine addiction,
and Alzheimer’s disease.
Expanding strategies for vaccine development are
incorporating molecular approaches such as DNA,
vector, and peptide vaccines. New technologies,
such as the use of transdermal and other needle-

118
less routes of administration, are being applied to
vaccine delivery.

119
Prevention offers greatest promise of reducing
cancer mortality due to viruses. Prevention can be
accomplished by 3 strategies:
(1) early screening for tumours,
(2) screening for the virus with prevention of
transmission, and
(3) immunization.
Early screening is exemplified by cervical smears.
Screening to prevent iatrogenic transmission via
blood & blood products is routinely employed for
potentially oncogenic viruses as HBV, HCV, HIV, &
HTLV-1.
In Kyushu, Japan, where infection was endemic,
HTLV-1 is being steadily eradicated through policy of
antenatal screening to prevent transmission via milk.
Prevention of cancer, by immunization against
infection, by oncogenic viruses, is likely to have
major impact on world cancer mortality. HBV
vaccine is based on surface antigen & 2HPV vaccines
protective against cervical cancer were licensed in
2006.

120
Intensive research is also being undertaken on
vaccines for HIV & HCV, but there are immense
obstacles to successful immunization against HIV as
the virus is extraordinarily variable.
Nevertheless, immunization against oncogenic
viruses is becoming a most effective cancer
prevention strategy.

121
Rules for Vaccinating Certain Populations
1. Allergy—Thimerosal, egg, latex, preservatives
■ Eggs—Do not give yellow fever vaccinations
■ Streptomycin/neomycin—Do not give inactivated
poliomyelitis (IPV), measles/mumps/rubella (MMR)
2. Live vaccines—Give 1 month apart, or at separate
sites
3. Pregnancy—No live vaccinations (MMR, varicella,
LAIV)
4. Breastfeeding—Safe to vaccinate except smallpox
& yellow fever
5. Preterm infants:
■ Vaccinate based on chronological age, not from
birth date
■ Must be >2 kg for first hepatitis B vaccination
6. Anaphylaxis/encephalopathy/CNS complication
with DTaP—Can give only DT (no pertussis)
7. Previous vaccination reaction—There are no
contraindications for further vac. Note vac reaction:
■ Temperature <40.5°C
■ Redness, swelling, sore at injection sit
8. Asplenia—Requires pneumococcal, HiB,
meningococcal, influenza
9. Influenza—Those receiving their first ever
122
vaccination, between 6 months & 9 years require
two immunizations at a minimum of 4 weeks apart.
Any time thereafter can be a solo injection. Also, live
attenuated vaccination is contraindicated in those
under 2 years of age, due to increased incidence of
wheezing.
■ Of note: Potential up-coming vaccine: Bexsero. It
is a multicomponent vac for meningococcal
serogroup B (4CMenB). Men B is now most prevalent
serogroup (which has no current vaccine coverage).
This vaccination can be considered in certain
situations, mainly those individuals at highest risk of
contracting invasive meningococcal disease.
■ Also, Gardasil 9 has approved & IS readily available
as it covers 9 strains of HPV rather than the previous
4 strains.

123
Contraindications to Vaccines
Vaccines contraindicated in Pregnancy: All live vaccines
EXCEPT Yellow fever vac
• Vaccines contraindicated in HIV:
– Asymptomatic HIV: NONE
– Symptomatic HIV: All live vaccines EXCEPT BCG vaccine
• Vaccines contraindicated in Immuno-suppression: All
live vaccines
• Vaccines contraindicated in Corticosteroid therapy: All
live vaccines
• Vaccines contraindicated in fever: Typhoid vaccines
– Typhoral – Typhim – Vi – TAB
• Vaccines contraindicated in ARTI/ diarrhoea: NONE
• Vaccines contraindicated together: Yellow fever and
Cholera vaccine
• Vaccine contraindicated in Preterm-premature baby
with birth weight < 2 kg: Hepatitis B
• Vaccines contraindicated in age < 1 year (infants):
– Yellow fever vaccine – Meningococcal vaccine
– Pneumococcal vaccine

124
125
 Following vaccinations are not yet compulsory in
Egypt but recommended & available:
• Rotavirus vaccine
• Prevenar (pneumococcal saccharide conjugate
vaccine)
• Chickenpox (varicella) vaccine
• Hepatitis A vaccine
• Meningitis vaccine
• Typhoid Fever vaccine

EG PT

EG PT

126
Human immunoglobulins & non-human antisera

127
128
 • There are many approved indications, as well as off-
label uses, for IVIG.
• The therapeutic dose of IVIG is set empirically at 2
g/kg.
Often this dose is given in five daily doses of 400 mg/kg
each, but it may be preferable to divide the total dose
into two daily doses of 1 g/kg if the patient can tolerate
the volume of the infusion.

129
Primary immunodeficiency states doses:
• In primary immunodeficiency states, monthly doses
of between 100 & 800 mg/kg are administered, with
average dose being 200–400 mg/kg.
• immunodeficiency states where IVIG is given include
both antibody deficiencies & combined immune
deficiencies.
• Significant reactions can occur in patients with low
intrinsic levels of IgA given IVIG with greater
amounts of IgA. An IVIG product with very low
amounts of IgA should be used for these patients.
• IVIG is indicated for some patients with HIV
infection; however, the data to support its use are
better in the pediatric population.
• With the advent of new antiretroviral agents and
combination therapies, the usefulness of IVIG may
be even more limited.

130
FUTURE TRENDS IN VACCINES
Although most vaccines developed in twentieth
century targeted common acute infectious diseases
of childhood, more recently developed vaccines
prevent chronic conditions prevalent among adults.
Hepatitis B vaccine prevents hepatitis B–related
cirrhosis and hepatocellular carcinoma
zoster vaccine prevents shingles &d postherpetic
neuralgia, and HPV vaccine prevents some types of

131
 cervical cancer as well as genital warts and
anogenital cancers.
New targets of vaccine development and research
may further broaden the definition of vaccine-
preventable disease.
Research is ongoing on vaccines to prevent insulin-
dependent diabetes mellitus, nicotine addiction,
and Alzheimer’s disease.
Expanding strategies for vaccine development are
incorporating molecular approaches such as DNA,
vector, and peptide vaccines. New technologies,
such as the use of transdermal and other needle-
less routes of administration, are being applied to
vaccine delivery.

Vaccine as immunotherapy
Herpes virus infection v ↓r f recurrence
Leprosy: BCG potentiates chemotherapy effects
Tuberculosis: a new vaccine made of Mycobacterium
vaccae potentiates effects of antibacterial agents, even
in patients resistant to therapy

132
HIV infection: vaccination ē killed HIV may alter TH1:TH2
balance in favor of TH1 cells which are more effective
mediators of anti-HIV responses

133
General guidelines for VAC administration

Package insert should be consulted for:

Manufacturing date
nature
content
contraindications
side effects
storage
administration
Multiple Doses: If series is interrupted, continue as
if it had not been interrupted
Do not count (as part of primary series) doses given
at less than recommended intervals
Simultaneous administration: Inactivated vaccines:
given at separate sites
live attenuated viral vaccines: given on the same
day, otherwise at least one month apart

134
 inactivated & live attenuated at same time except,
cholera & yellow fever separate them by at least 3
weeks
Administration of IG & vaccine
Inactivated vaccines:
have large antigenic load, do not require
multiplication in body, so can be given any time after
IG. If given simultaneously, must be at different sites
Live attenuated viral vaccines:
have small antigenic load, require multiplication in
body, & can not be given with IG
a) live vaccine should not be given for at least 6
weeks (better 3 months) after injection of IG
b) If IG has to be given <14 days after administration
of a live vaccine, vac should be repeated after 3 m of
IG
c) IG does not interfere with oral polio or yellow
fever

135
Reactions to vac components
Egg hypersensitivity:
some vaccines (e.g., yellow fever, measles, mumps,
influenza) are grown in embryonated chicken eggs.
any vac grown on embryonated chicken should not
be given to anyone ē known anaphylactic
hypersensitivity to eggs
Preservative hypersensitivity:
some vac contains preservatives as thimerosal (a
mercurial) or neomycin (MMR, Varicella) they should
not be given to individual who have anaphylactic
reactions to these agents.
Penicillin allergy: no currently recommended vac
contain penicillin or its derivatives. Therefore, a
history of penicillin allergy is not a contraindication
to immunization
Immunocompromised individuals:
Should not be given a live attenuated vaccine
(except HIV you can give MMR)
since recipients of oral polio vaccine, excrete vaccine
strain in their stool, OPV should not be given to

136
 individuals who live in households with
immunocompromised hosts.
Severe febrile illness:
Should NOT BE IMMUNIZED TILL COMPLETELY
RECOVERED. Primarily to avoid blaming a vaccine for
a manifestation of underlying disease
Pregnancy & vaccination:
Live attenuated vaccines should not be given to a
pregnant woman or to those likely to become
pregnant within 3 months of receiving the vaccine
pregnant women at substantial risk of exposure MAY
receive live viral vaccine, when possible, during 2nd
or 3rd trimester
There is no evidence that inactivated vaccines or IG
poses any risk to the fetus. In fact, women
incompletely immunized against tetanus should
complete their primary series during the last
trimester of pregnancy
children of pregnant women should receive age-
appropriate vaccination

137
 Misconception about contraindications:
following are NOT reasons for delaying vaccine:
1. soreness, redness, or swelling at site of injection or
temp less than 38.5 0C in reaction to previous DPT
2. mild acute illness with low grade fever
3. mild diarrheal illness in a well child
4. current microbial therapy
5. convalescent phase of illness
6. pregnancy of household contact
The following are NOT reasons for delaying vaccine:
➢ prematurity: immunizations should be given on basis
of chronologic age, the vaccine dose should not be
reduced
➢ recent exposure to communicable dis.
➢ breast feeding
➢ a history of nonspecific allergy
➢ relatives with allergy
➢ family history of convulsions

138
139
140
141
142
 COLD CHAIN & Storage of vaccines

Sensitivity to Cold: Some vaccines are also sensitive

to being too cold.
For these vaccines, freezing or exposure to temp<
0° → f , & ,v
useless.
For these vaccines, it is essential to protect them
from heat, & from freezing.
The vaccines sensitive to freezing (as well as to heat) are
given in coming Box

143
 Sensitivity to Light: Some vaccines are very sensitive
to strong light, so must always be protected against
sunlight or fluorescent (neon) light.
BCG, measles, MR, MMR & rubella vaccines are
sensitive to light (as well as to heat).
these vaccines are supplied in vials made from dark
brown glass, which gives them some protection
against light
damage,
but care must still be taken to keep them covered &
protected from strong light at all times maintained, all
potency will be lost, & vaccine be useless.
144
 Expiry Date: Even when stored at correct temp, vac
do not retain their potency forever, & so all vac have
an expiry date
Diluents for Vaccines: Diluents for vaccines are less
sensitive to storage temp than vaccines ē which they
are used, but may be kept in cold chain between
+2°C - +8°C.
When vac reconstituted, diluent should be at same
temp as vaccine. So sufficient diluent for daily needs
should be kept in cold chain at point of vaccine use.
However, diluent vials must never be frozen. This
will risk cracking glass & allowing contamination of
contents, so diluent vials must never be kept in a
freezer, or allowed to be in contact with any frozen
surfaces.
Each vaccine requires a specific diluent & therefore,
diluents are not interchangeable.
Likewise, diluent made by one manufacturer for use
with a certain vaccine cannot be used for reconstituting
same type of vac produced by another manufacturer.

145
 Cold Chain
= system of transporting & storing vac at
recommended temp from manufacturer to point of
use.
All vaccines can be stored at temp +2°C to 8°C.
However, for long term storage, OPV & measles can
be stored at subzero temperature in deep freezers.
DPT, DT & TT should never be frozen. Also, BCG &
diluent ampoules should not be frozen.
Diluents required for measles & BCG should be
stored at +2°C to +8°C in refrigerator
Cold chain includes:
●W k r (W ) ● fr z r ●
Ice - lined refrigerators (ILRs)
● fr r r ● x ● rr r ●
Day carrier ● k
Walk In Cold Rooms: These are used for the storage of
large quantities of vaccines. They require constant
electric supply.
Vaccines can be stored up to 3 months. They serve a
region of 4-5 districts.
Deep Freezers & ILRs: These are provided at the district
146
and CHC level and can store up to 1 month supply of vac.
Capacity is 300/240 L. They can be used for storing OPV
& measles. Ice packs are also prepared at them.
Small Deep Freezers & ILRs: provided at PHC & can store
up to 1 m supply of vac. Capacity is 140L. They do not
have a freezer compartment.
Refrigerators: While using a refrigerator for purpose of
k v , r ’ & ’ v f
shown in coming box.
Vaccine Carriers: Used for transporting small quantity of
vac to sub center. These are made of insulating material.
Each carry four ice packs. The vaccines should be used on
same day. They should be kept away from direct sunlight.
Day Carriers: made of insulating material & carry 2 ice
packs. They can keep few vials for 6-8 hrs at a time.
Ice Packs: = flat plastic water bottles filled with water.
They are available in 3 capacities: 400ml, 500ml & 600ml.
Prepared by keeping in freezer.
Quality of Cold Chain: is monitored by MOH. The quality
check is done before release of vaccines. Reverse Cold
Chain is maintained to check vaccines for their potency.
Vaccine stock management: Vaccine stock management
is done at 3 points:
●W v ts arrive at storage point
147
●W v & remain in storage
●W v & k leave a storage point.

148
Recommended Storage Temperatures:

149
150
151
152
153
154
 International Vaccination Requirement
Immunization Against Yellow Fever
Yellow fever (YF) is endemic in tropical regions of Africa
& South America. Vaccination is the most effective
method for prevention of dis during international travel.
2 types of vaccines are available.
(i) 17 D Vaccine: This is the approved vaccine, for
international travel. It is live attenuated, chick embryo
grown, 17D-strain, freeze-dried, vaccine. For storage, at
WHO approved centers, vaccine kept for 3 months, at
+4°C. If storage, is for a longer period, temp of -25°C, is to
be maintained. After reconstitution, it should be used
within half an hour.
(ii) Dakar Vaccine: also called French Neurotropic
Vaccine developed at Pasteur Institute Dakar.
It is thermo-stable & can be easily transported.
However, it has produced post-vaccinia encephalitis in
children. WHO, has not approved, use of this vaccine for
international travel.
Administration of YF vaccine: 17-D vaccine given SC at
insertion of deltoid in a single dose of 0.5 ml. Immunity
begins in 10-12 ds & lasts for 10 Ys but persistence of

155
neutralizing ab 30-35 years, after immunization with 17D
YF vac, observed. YF vac available at centers certified by
Government. International certificate of vaccination is
required only for YF. Period of validity of certificate is
shown in coming Table

Protection recommended against certain other dis

for international travelers but international
certificate is not required. These are as follows:
(a) Cholera: Cholera vaccine may be taken by all
travelers proceeding to endemic areas. It offers
partial protection against the disease.
(b) Enteric Infections: Vaccination & revaccination
against typhoid is strongly advised for all travelers
proceeding to endemic areas.
(c) Hepatitis A: single IM injection of human normal
immunoglobulin 500 mg or 1.2 mg/kg body weight
effective immediately & its efficacy lasts for six

156
months. Active immunization with HAVRIX is
available
(d) Tetanus: A booster dose of Tetanus toxoid taken
if 5 years or more elapsed since last injection of a
complete course or booster.

157
Recommended Pre-exposure Prophylaxis for
International Travel & Postexposure
Immunoprophylaxis

158
159
 Immunization in Special Circumstances
1. Immunization in preterm infants: All vaccines
given as per schedule irrespective of birth weight or
period of gestation except Hepatitis B.
If wt of baby < 2 kg & mother is HBsAg negative,
then Hepatitis B vac is postponed till baby wt of 2 kg
or 2 months of age.
However, if mother is HBsAg positive, then both
Hepatitis B vaccine & Hepatitis B immunoglobulin is given
in 12 hrs of birth followed by 3 more doses at 1, 2 & 6-12
months.
2. Children receiving corticosteroids: Children
receiving corticosteroids at dose of 2 mg/kg/day for
more than 14 days should not receive live virus
vaccines until steroid discontinued for at least 1
month.

160
5. Lapsed Immunization: A lapse in immunization
schedule does not require reinstitution of the entire
series.
Immunization should be given at next visit as if usual
interval elapsed & immunization schedule should be
completed at next available opportunity.
In case of an uncertain immunization status, it is
appropriate to start schedule as soon as possible

161
162
163
164
165
166
167
6. Immunization of Adolescents: Reasons for
adolescent immunization fall into the following broad
categories:
a. To boost waning immunity by giving booster doses.
b. To counter a specific risk e.g., due to travel, life style
etc.

168
169
Clinic for Vaccine Administration
Key Issues:
◆ Basic Principals of Vaccine Administration
Techniques*
◆ Communication
◆ Recommended Vaccine Administration
Routes
◆ Appropriate Injection Sites & Needle Sizes
◆ Standard Precautions
◆ Pain Control Measures
◆ Atraumatic Care (Children)
◆ Preparation
◆ Positioning
◆ Positive Reinforcement (comforting
techniques)
* Intended for the education of licensed medical
personnel
Communication:
◆ Discuss vaccines indicated on this visit

170
◆ Use of Vaccine Information LEAFLETS
◆ Identify any precautions or contraindications
◆ Encourage questions
◆ Address concerns
Inform of next immunization due date ‫تاريخ االستحقاق‬
Importance of Administering Vaccines Correctly:
Ensure Optimal Vaccine Efficacy: For
example, upper outer quarter of buttocks is
not a recommended site for any of vac
r v ←
significant layer of a fat
possible danger to sciatic nerve
↓ f v f v
in gluteus maximus.
↓ Localized & Systemic Reactions:
In general, vac containing adjuvants (DTaP,
Td, DT, HepB or HepA) should be injected into
muscle mass ← when given SC, → local
irritation, inflammation, & even granuloma
formation
↓ P r z
171
Routes of Administration:
It is important to use correct route when giving
vaccines.
172
Insert needle at appropriate angle to insure delivery
to muscle or subcutaneous tissue
So, there is little local, neural, vascular or tissue
injury.
IM:
Angle of needle is perpendicular to skin to so certain
muscle is reached.
Introduce needle ē a quick thrust.‫دفعة‬
Retain pressure on skin around injection site with
thumb & index fingers of the other hand for entire
time, needle is inserted.
SQ:
The angle of needle insertion is 45 degrees to skin.
Press up a bit of subcutaneous tissue ē other hand
may help prevent in advert IM injection.
Choice of Site & Needle Size: Based upon:
◆ Age Volume of material
◆ Viscosity of material
◆ Size of muscle
◆ Recommended depth

173
Recommended Vaccine Administration Routes

174
175
176
IM Injections: Infants & Toddlers:
Generally, for IM injections, needle should be long
enough to reach muscle mass &
prevent vaccine from seeping into SC tissue,
but not so long as to injure underlying neurovascular
structures & bone.
What sites are correct for IM injections for Infants?
Infants (0-12 m): Vastus Lateralis in anterolateral
aspect of middle or upper thigh used for infants,
What size needle is appropriate for infants?
“ r f (very young & small) a 5/8 “ may
” f r , 78
As for recommended gauge of needle, 22-25 gauge.
A 22 gauge is really big lumen for most vaccines & a
23 would be ok & less painful.

177
178
179
180
Standard Precautions during immunization:
◆ Gloves not required, but may be indicated.
◆ Do not recap used needles or separate needle
& syringe.
◆ Discard syringe & needle in a puncture proof
sharps container & discard container correctly
◆ Follow rules & legislation for “Needlestick
Safety & Prevention”
Filling Syringes:
➢ There should be 15 doses, in a 15-dose vial, & 10
doses, in a 10 dose vial.
➢ Usually, all doses may be obtained, by utilizing
proper syringe loading technique, (e.g., injecting air,
inverting vial, drawing out just the required amount
of vaccine for the dose.
➢ Do not overcompensate. ‫يعنى ال تحاول تعويض اي نقص‬
➢ Avoid squirting any vaccine in the air.
Multiple Injections:
• When necessary, 2 or more vac may be given in the
same limb.

181
• Distance for separating 2 injections, should be
sufficient (e.g., 2-3 cm apart) so that, local reactions
are unlikely to develop.
• Consider possibility of local reactions when
choosing sites.
• Do not mix multiple vaccines in a single syringe,
unless specifically licensed.

182
 Special Considerations in immunization
Mastectomy:
• Do not use arm on the side of the mastectomy
• If double mastectomy, use another site other
than the arm (Leg)
Hemophilia
• When Hepatitis b or any other IM vaccine is
indicated for a patient with a bleeding
disorder, it should be administered IM if in the
opinion of the MD familiar with the patient’s
bleeding risk can be vaccinated
intramuscularly.
• Try to give the vaccines immediately after the
receipt of the replacement factor
• Use a 23 or smaller gauge needle
• Immediate application of firm pressure to site
for at least 2 minutes
• Instruct family of risk of hematoma
Lost Immunization Records
• Give what is age appropriate on that visit and
instruct parent to look for record. If unable to
183
 locate, must give all the vaccine doses that are
appropriate for age.
Record Keeping: Required documentation of:
o Date of administration
o Manufacturer
o Lot Number
o Name, address, & title of person administering
vac
o Adverse effects (if any)
o Publication Date of VIS
o Client’s Personal Immunization record
Management of Reactions &
Reporting of Adverse Events:
? Accessible & Maintained Emergency Kit
? Staff certified in CPR
? Conduct emergency drills
? Complete “Incident Report” for reaction
? Vaccine Adverse Events Reporting System (VAERS)

184
 Pain Control in immunization:
◆ Acetaminophen or Ibuprofen
◆ Pressure to site before &after injection
◆ Ice or cold compresses
◆ Atraumatic Care

185
Preparation for immunization: W ”
• What to expect
• f x “j ”
• Assess what has worked in past
• Team approach, invite parents
• Plan for focusing techniques (imagery, deep
breathi , r , ’ )
• f ↓
Positioning for Comfort during immunization:
* Close physical contact ē parent or caregiver.
* Caregiver participates in +ve assistance, not -ve
restraining ‫تقييد‬
* Sitting positioning promotes sense of control for
child.
* Immobility of extremity is successful.
* Fewer people needed to perform procedure.

186
Positive Reinforcement during immunization:
☺ Point out when they are doing their job
☺ Verbal praise
☺ Rewards
(d ’ f r ,“’ rr ” & r +v f
procedure is needed)

187
Positioning for immunization:
◆ IM: Position limb to allow relaxation of
muscle injected
◆ Deltoid: flex arm
◆ Anterolateral thigh: some degree of
internal rotation
Infants & Young Children:
Hold securely in parent’s lap
Older children:
◆ Sit on parent’s lap or edge of exam table &
hug parent’s chest
Adolescents & adults should be seated for imz

188
189
190
 Some
Clinical Issues in
Infections

Beginning from here, some important

clinical issues, will be mentioned, why?
Because practice of preventive medicine
needs them.
Firstly, to carry epidemiological
surveillance,
secondly, to do preventive measures for
contacts of infectious diseases,
thirdly to prevent non communicable, and
occupational diseases.

191
 Major manifestations of
infection, practical look

INTRODUCTION
Definition:
Infection is multiplication of microbes (viruses,
bacteria, fungi, protozoa, multicellular parasites, or
prions) in tissue of host.
Micro-organism-host interaction:
Each person can be colonized with huge number of
micro-organisms (bacteria, plus viruses, fungi,
protozoa & worms). Relationship in some of these
organisms is symbiotic = both partners benefit,
others are commensals living on host with →
harm. Infection & illness may be ←:
1. Normally harmless commensals & symbiotes
evading body's defenses & penetrating into
abnormal sites.
2. Exposure to exogenous pathogenic organisms
which are not part of human normal flora.
Interaction between host & pathogens results in
192
 symptoms & signs of infection which are ←:
1. Killing of host cells by invading organisms.
2. Combination of direct microbial pathogenicity &
body's immune response to infection.
Immune response to infection:
I- Innate immune mechanisms:
1- Exterior defenses e.g., epithelial cells, lysozymes and
normal flora.
2- Complement cascade: initiation of complement
cascade is antibody independent and referred as
alternative pathway
3- Professional phagocytes including:
- Polymorphonuclear neutrophils (PMNs)
- Tissue macrophage
Both have recognition receptors e.g., toll like receptors
(TLR) and CD14.
Function:
Engulfing many pathogens directly (phagocytosis)
Bounding of antibody and/ or complement to bacterial
pathogens (opsonization).
Effect:
Activation of macrophages and PMNs lead to secretion
of a number of cytokines.
193
Adaptive immunity to infection:
✓ It is the antigen-specific, T cell dependent, immune
response that develops when innate immune
defense mechanisms are unable to control an
infection.
✓ This response develops over several days, the time it
takes antigen-dependent T and B cell lymphocytes to
proliferate & differentiate to effector cells
✓ 1 Humoral immunity (antibody response):
humoral immune response is most effective against
extracellular pathogens. Specific antibodies serve
three main functions in host defense.
i- Neutralization:
Binding of antibody to bacterial toxins prevents
them from interacting with host cell targets
neutralized toxins, bound to specific antibody, can
then be ingested & degraded by macrophages.
ii- Opsonization:
Bacteria in extracellular space can become
opsonized (coated with specific antibody). These
opsonized bacteria recognized by macrophages,
→ bacteria to macrophages via Fe portion of
antibody molecule & Fe receptor on macrophage

194
 surface. The bound bacteria are then ingested &
degraded.
iii- Complement activation:
Bacteria bound with specific ab can activate
"classical pathway" of → irect killing
of pathogen.
2- Cell-mediated immunity (CMI):
CMI responses are most effective against intracellular
pathogens.
Intracellular pathogens can reside either in phagocytic
vesicles or free in host cell cytoplasm. 2 types of CMI
r ē 2 pathogenic stages
1) Pathogens that survive in pathogenic vesicles of
macrophage as TB controlled by T cell dependent
mechanism of macrophage activation
2) Pathogen that resides free in cytoplasm as viruses, &
certain bacteria (listeria, shigella) are controlled by
CD8 cytotoxic T cell lymphocytes (CTL)

195
 HISTORY TAKING IN INFECTION
Patient
•
– Children & very old are more susceptible than young
adults to some types of infectious disease.
• x r r r f x-
specific diagnoses:
– Epididymo-orchitis or prostatitis in men.
– Pelvic inflammatory disease or tampon-related toxic
shock syndrome in women.
•
– Contact with animals raises possibility of zoonotic
infections.
– Healthcare workers may acquire infectious diseases
from their patients.
• -morbidity and immunosuppression:
– Some infectious diseases (e.g. bacterial meningitis or
pneumococcal pneumonia) can affect even previously fit
and healthy individuals.
– Most infectious diseases are more common in
immunosuppressed individuals, although the
presentation might be blunted or less severe.
– Certain co-morbidities raise the risk of specific types of
infection, e.g. incomplete bladder emptying in
196
neurological disease raises the risk of urinary tract
infection (UTI).
– Significant immunosuppression (e.g. in organ
transplant recipients or patients with significant bone
marrow disease) increases the risk of infection by a wide
range of atypical (opportunistic) pathogens, including
fungi, low-pathogenicity viruses and non-tuberculous
mycobacteria.
• -economic status
– Malnutrition, poor sanitation, homelessness and
overcrowding increase the r k f r f‘
f v r ’
• v
– People who inject drugs are at risk of blood-borne
viruses and bacterial bloodstream infection.
– Unprotected sex presents the risk of developing body-
fluid-borne viruses and various sexually transmitted
infections.
– Freshwater swimming is a risk factor for leptospirosis
and (in certain regions) schistosomiasis.
– Domestic pets can transmit disease, including cat-
scratch fever or toxoplasmosis.
•
– Diseases that occur in outbreaks (e.g. food poisoning)
197
may also present in household or other close contacts.
• x r
– Where a diagnosis is unclear, taking time to revisit the
history and ask about any unusual activities or exposures
is sometimes helpful. Activities that may not be common
in a particular setting, e.g., caving, cleaning aquariums,
art restoration or repairing air-conditioning systems, all
carry risks for developing particular infectious diseases.
Unless you ask, you may v r f  
• Place
• r v r
• r v r r r
a risk factor for a wide range of infectious diseases,
including malaria, dengue and typhoid.
• r f , r r
viral hepatitis, may be acquired during childhood
spent in endemic regions and then present in
adulthood.
• r localized epidemics, as
Middle Eastern respiratory syndrome (MERS) or
Ebola (Central Africa), should be borne in mind

198
 • r
– Nursing or residential home residents are at risk of
developing infectious diseases that are usually
( ‘
q r ’ r Clostridium difficile
infection).
– There are significant global differences in antibiotic
resistance rates, so patients who were inpatients in,
or travelled to, other countries may present with
multi-resistant organisms not usually seen in their
country of residence.
• Time
• f f r r
the development (and perhaps resolution) of
different symptoms over time.
• f acute viral and bacterial
infectious diseases emerge over several days.
• r f r k
chronic infection (e.g. tuberculosis, leishmaniasis,
brucellosis, human immunodeficiency virus (HIV)) or
non-infectious (e.g. autoimmune or malignant)
disease process.
• r f v r
virulent organism and may imply the need for urgent
199
 and empirical treatment before a diagnosis is made.
• v r r r ,
e.g. the biphasic febrile response in dengue, or the
‘K f v r’ f r
in Schistosoma haematobium f  
• Symptoms
• Pr r f ff r r
and organ-specific symptoms experienced by the
patient is crucial.
• ,
always requires empirical antibiotic therapy.
• v v f
particular anatomical site or organ system, such as
localized pain, jaundice or the bloody diarrhoea of
dysentery.
• r , , v r
watery diarrhoea, often occur non-specifically in
various infectious and non-infectious diseases, and
should not be presumed to imply neurological or
gastrointestinal disease, respectively.
• f diseases have unique pathological
features that, if properly described, are highly
v f r r , ‘ r

200
 r ’r f , r r r v
phases of typhoid.

201
 EXAMINATION in Infection

Major manifestations of infection

202
Summary of clinical picture & management of infection
203
204
205
206
207
208
209
210
211
212
213
 FEVER
✓ Definition: FEVER
=↑ > r r v r ←
change in thermoregulatory center, in anterior
hypothalamus.

GUIDING QUESTIONS:
1. Which region of brain is primarily responsible for
temperature regulation?
2. Does core temperature vary at different times of
the day?
3. Is fever beneficial?
4. How & when should fever be treated?
5. How do acetylsalicylic acid (ASA) &
acetaminophen act to reduce fever?
TEMPERATURE REGULATION:
➢ Body temp regulated by anterior hypothalamus in
combination with many other neural structures,
including brain stem, spinal cord, & sympathetic
ganglia.
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➢ Region of hypothalamus, near optic chiasm, is
r f r ’
core temp.
➢ A distinct temperature set point is established, &
when bod ’ r erature drops, below set
point, CNS ↑ body metabolism & stimulates
shivering & chills.
➢ When core temperature, exceeds that set point, CNS
↑ peripheral bl flow & sweating occurs.
➢“ r ” 37°C, & varies from
individual to individual, following a normal
distribution.
➢ So, some individuals, have a lower set point, &
r v r , “ r ”
temperature.
➢ r r r , v ’ r v r ,
during day, being lower in morning & ↑ in evening.
Before diagnosis a patient to have a fever, physician
f rē ’ r &
diurnal core temp variation.

215
 ✓ Normal body temp for individual 18-40 ys is 36.8 ±
0.4°C with a nadir ‫ اقل مستوى‬at 6 am & a peak at 4-6
pm.
✓ By this criterion, an am temp > 37.2 °C or a pm
temp> 37.7 °C would define a fever.
✓ This diurnal variation preserved in most forms of
febrile disease but is lost in hyperthermia.
Fever is a characteristic feature of most infections but
found also, in a number of noninfectious dis as
autoimmune & inflammatory diseases
• Normal daily temp variation is typically 0.5°C (0.9°F).
• However, in individuals recovering from a febrile
illness, this daily variation may reach 1.0°C.
• During febrile illness, diurnal variation, usually
maintained, but at higher, febrile levels.
• Daily temp variation, fixed in early childhood;
• In contrast, elderly individuals can exhibit ↓ ability
to develop fever, with only a modest fever even in
severe infections.
• Rectal temperatures are generally 0.4°C (0.7°F)
higher, than oral readings

216
 • Lower oral readings r r ←
breathing, which is a factor in patients with
respiratory infections & rapid breathing
• Lower-esophageal temperatures closely reflect core
temperature. ‫هام‬
• Tympanic membrane (TM) thermometers, measure
radiant heat from tympanic membrane & nearby ear
canal & display that absolute value (unadjusted
mode), or a value automatically calculated from
absolute reading on basis of nomograms relating
radiant temperature, measured to actual core
temperatures obtained in clinical studies (adjusted
mode).
• These measurements, more variable than directly
determined oral or rectal values.
→ readings are lower with unadjusted-
mode, than with adjusted-mode TM thermometers &
that unadjusted-mode TM values are 0.8°C (1.6°F) lower
than rectal temperatures.
• In women who menstruate, A.M. temperature is
lower in 2 weeks before ovulation;

217
• it then rises by ~0.6°C (1°F) ē ovulation & remains at
that level until menses occur.
• Body temp can ↑in postprandial state.
Pregnancy & endocrinologic dysfunction also affect
body temp.
MECHANISMS UNDERLYING FEBRILE RESPONSE:
• Fever is a consequence of anterior hypothalamus
responding to inflammatory mediators.
• r ,↑ r r erature set
point, are interleukin 1 (IL-1), tumour necrosis factor
α( -α), r k 6 ( -6), & rf r γ ( -γ)
• These cytokines, released by monocytes &
macrophages, in response to invasion, by pathogens
& by other inflammatory stimuli.
• Cytokines stimulate circumventricular organs, near
optic chiasm, activating phospholipase A2, which in
turn stimulates cyclooxygenase, to produce ↑ levels
of prostaglandin E2.
• Which crosses bl–brain barrier, & stimulates
neurons in anterior hypothalamus & brain stem,
responsible for thermal regulation Pathogenesis of
fever:
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 - normal body temp maintained despite
environmental v r ← f
thermoregulatory center to balance heat production
with heat dissipation.
• With f v r, f ↑ r
- Pyrogens initiate fever, by their effects on
hypothalamus heat regulation.
• They may be endogenous (produced by
macrophages & monocytes) or exogenous (from
outside body e.g., organisms & their products).
- Production of cytokines (IL2, IL-4, IL-6, & )→↑
production of prostaglandin E2 (PGE2).
• This prostanoid, has peripheral & central effects;
• Peripherally, it is responsible for nonspecific
myalgias & arthralgias that often accompany fever.
Centrally, it starts process of raising hypothalamic set
point for core temp.

219
Accompaniments of fever:
• Myalgias, arthralgias, & anorexia ← r r
effects of PGE2, & abolished with use of cyclo-
oxygenase inhibitors (aspirin)
• Chills = sense of cold occurring, as part of CNS
response, to new setpoint, calling for more heat
• Rigor is a profound chill ē shivering, & piloerection.
• Sweats: occur ē v f ←
effect of antipyretic (changing hypothalamus set
point), or elimination of febrile stimulus.
• Febrile convulsions: occur in those < 5Ys
• Acute phase reactant: proteins affected, in acute
→↑ , f rr , r v
protein & fibrinogen
BENEFITS & HARMFUL EFFECTS OF FEVER
✓ Warning sign for onset of infection.
✓ Growth of some viruses, bacteria, fungi, & parasites
inhibited by ↑ in temp > 37°C.
✓ Fever enhances ability of macrophages &
neutrophils to kill pathogens & to improve cell-
mediated immune function.

220
✓ Fever may also have harmful effects.
✓ Pts ē heart dis, may suffer cardiac ischemia ← ↑ in
heart rate & oxygen demands associated ē fever.
✓ Pts ē severe pulmonary dis, may be unable to
compensate for ↑ oxygen demands associated ē
fever.
Elderly pts ē limited mental capacity, may develop
confusion & lethargy in response to fever,
complicating their care.

221
 Control of fever
1. Physical cooling:
a. Cold foments
b. Cooling blankets
c. Ice bath
2. Resetting hypothalamic set point & alleviating
f ē r
Aspirin:
Mechanism: cyclo- x r & ↓PG 2
formation peripherally & centrally.
Side effects: allergy, gastric mucosa irritation, bleeding
tendency & Reye’s ‫ هام‬syndrome (acute encephalopathy
& diffuse micro vesicular fatty infiltration of liver) which is
fatal in 50% of cases ← cerebral edema, if used in
children ē viral dis

222
Acetaminophen:
Mechanism: it lacks peripheral inhibitory effect on PGE2
synthesis, so has no anti-inflammatory actions, but it
↓its synthesis centrally, so its potent antipyretic effect
Side effects: few when compared ē aspirin. Remembered
> r , r →f
liver failure.
NSAIDs:
These are potent antipyretics & anti-inflammatory.
Examples include diclofenac, indomethacin & ibuprofen.

TTT OF FEVER
✓ 1ry ttt for fever is to treat underlying cause.
✓ Role of lowering body temp, while trying to
determine 1ry cause of fever remains controversial.
✓ Based on current understanding of thermal
regulation, direct cooling of body by using ice, cold
water, or a cooling blanket should be considered
only, in conjunction with medicines that reset
thermal set point.

223
✓ Otherwise, CNS will respond to such measures, by
& v r ,↑ ’ f r
Antipyretics is warranted in patients with heart
disease & pulmonary disease, & in elderly patients
with mental dysfunction ēf v r
✓ Pharmacologic agents, used to reset thermal set
point, inhibit prostaglandin synthetase activity & ↓
prostaglandin E2 production. Acetylsalicylic acid
(ASA), nonsteroidal anti-inflammatory drugs
(NSAIDs), & acetaminophen are all effective.
✓ In children, ASA avoided ← ↑r k f Reye’s
syndrome (a deadly syndrome consisting of fatal
hepatic & renal failure), &
✓ Acetaminophen avoided in patients with serious
underlying liver disease.
✓ Coronary artery vasoconstriction ē
NSAIDs, & so those drugs not used in patient ē
ischemic heart disease.
To avoid repeated shifting of thermal set point &,
recurrent shivering & chills, antipyretic agents must be
given on regular schedule until primary cause of fever
treated.

224
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DD of fever

228
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230
231
232
 MANAGEMENT OF NEW ONSET FEVER IN
HOSPITALIZED PATIENT
One of most common problems, seen in infectious dis,
is evaluation of, new onset fever, in patient managed
for, another medical problem, in the hospital. They
often have multiple medical & surgical conditions &
may appear severely ill.
In postoperative patient, wound infection first
excluded. All surgical wounds carefully examined, for
purulent discharge, erythema, edema, & tenderness.
In immediate postoperative period (24-48 hours),
Streptococcus pyogenes → septic shock & severe
bacteremia ē only minimal purulence at operative site.
A Gram stain of serous exudate usually demonstrates
gram-positive cocci in chains.
In later postoperative period, Staphylococcus aureus,
including MRSA, & nosocomial pathogens as
Pseudomonas, Klebsiella, & Escherichia coli are
associated ē wound infection.
In chronically ill patients, decubiti need to be
considered as a source of infection, & a full exam of

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back & buttocks for tissue breakdown & purulent
discharge.
The organisms associated ē deep decubiti include same
organisms as ē late postoperative infection, in addition
of anaerobes, including Bacteroides fragilis
• Appropriate antibiotic ttt is guided by, culture &
Gram stain. Empiric antibiotic ttt should include
gram-positive & gram-negative coverage. In pt who
have suffered bowel perforation, development of
intra-abdominal abscess is common cause of fever,
& abdominal CT scan ordered, to exclude this
possibility.
Because most ICU pts intubated, bacteria colonizing
nasopharynx can more readily gain entry to bronchi
& r r , → bronchitis &
pneumonia.
• Pts in less acute wards, are also at ↑ risk for
aspiration pneumonia, ← r r , v
suffered a stroke, or are receiving sedatives.
• Sputum Gram stain is imp to differentiate
colonization from true infection. Presence of a single
organism on Gram stain, combined ē more than 10
neutrophils per high-power field, strongly suggests
234
 infection. Sputum culture identifies offending
organism & sensitivities to antibiotics.
• Other parameters that are helpful, to differentiate
colonization from true infection, are chest X-ray
(CXR) & arterial blood gases. The presence of new
infiltrate supports diagnosis of pneumonia, as does
↓ arterial PaO2.
• Hospitalized pts may have several IV catheters in
place. These lines are risk of becoming infected, &
line sepsis is a common cause of fever in
hospitalized pts.
• At onset of new fever, all IV & arterial lines should
be examined for erythema, warmth, & exudate. Esp
in patient who developed shock, all lines removed &
appropriate empiric antibiotic coverage instituted
immediately (within 1 hour).
• Staphylococcus aureus, Staphylococcus epidermidis,
& gram-negative rods are 1ry causes of line sepsis.
• Initial antibiotic should include vancomycin & third-
generation cephalosporin.

235
• Empiric antibiotic individualized, to take into account
prevailing bacterial flora in each hospital unit, &
history of antibiotic use in the patient.
Pts in hospital for prolonged periods, & who received
multiple antibiotics, are at risk of candidemia,
especially if 2 or > peripheral site cultures have grown
this organism. These pts should be empirically covered
ē fluconazole or an echinocandin (caspofungin,
anidulafungin, or micafungin), pending blood culture
results.
• Another major infectious cause of fever, in
hospitalized pts, is prolonged bladder
catheterization.
• Bladder catheter bypasses urethra, & despite use of
closed urinary collecting systems, nearly all patients
ē bladder catheters develop urinary tract infections
in 30 days
• So, Urinalysis & urine culture must be part of fever
workup, in all pts ē urinary catheters.
• In pts ē nasogastric tubes, or those who intubated
through nasal passage, ostia draining air sinuses, can
→ &
fever. Fever workup in these patients, therefore
236
 needs to include sinus films. If sinusitis is discovered,
tube must be removed, from nasal passage, &
appropriate antibiotic coverage instituted
• Noninfectious causes of fever also need to be
considered.
• Pulmonary emboli may present ē fever. Pts are
usually, receiving large number of medications, &
, ↑r k f v r f v r
medications reviewed, & when possible, medications
should be discontinued or changed.
• Another cause of persistent low-grade fever is
undrained collections of blood. These collections
can be identified by CT scan. Generally, they do not
require drainage, but they take time to fully resorb.
• Fever in hospitalized patient requires a systematic
diagnosis & wise use of antibiotics. Too often, pts
given for prolonged periods, using broad-spectrum
→ selection of highly
resistant bacterial pathogens, & it also predisposes
pt to candidemia & Clostridium difficile colitis.

237
FEVER OF UNKNOWON ORIGIN

238
239
240
241
TAKING HISTORY OF FUO:
History plays critical role in narrowing DD & in deciding
on most correct diagnostic tests.
• A review of all $ associated ē illness needs to be
periodically updated.
• $ often are transient & recalled by pt‫ و‬only after
repeated questioning ’ r
often provides useful clues.
• History of tuberculosis, TB exposure, or a positive
PPD should be included.
• Family history thoroughly reviewed, to exclude
genetic disorders, as cyclic neutropenia & familial
Mediterranean fever.
• Social history includes animal exposure (pets &
other domestic or wild animals), home environment,
& occupational exposure.
• Travel history should explore travel to areas
endemic for malaria & other parasites, typhoid,
coccidiomycosis, histoplasmosis, & tick-borne
illnesses.

242
• A list of all medications, including over-the-counter
& natural organic remedies, must be compiled to
exclude the possibility of drug fever.

243
PHYSICAL EXAMINATION OF FUO
In addition to a careful history, careful repeat physical
examination is frequently helpful.
skin examination, looking for embolic or vasculitic
lesions or evidence of physical manipulation.
nail beds, where small emboli can become trapped in
r ff r & ,→ r-
shaped infarcts.
Joint motion & presence of effusions looked for.
eye examination repeated, looking for conjunctival
petechiae, conjunctivitis, punctate corneal lesions,
uveitis, optic nerve changes, & retinal or choroidal
abnormalities.
Thorough palpation of all lymph nodes documenting
consistency, size, & tenderness.
Cardiac examination repeated daily, listening for
cardiac murmurs & pericardial rubs.
abdomen palpated daily to detect new masses, areas
of localized tenderness, and hepato- or splenomegaly.

244
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246
247
 ‫الحمى المصطنعة‬

‫‪248‬‬
 Bacteremia, septicemia, septic shock
Definitions:
1-Bacteremia = presence of bacteria in the bl
2-Systemic inflammatory response syndrome (SIRS) =
f ← (r ,
infection, operation).
Temperature >38 or <36, Pulse >90, Respiratory rate
>20, WBCs >1200 or <4000
3-Sepsis = describe $ & $ of systemic inflammatory
response syndrome (SIRS) to a localized primary site of
infection.
Organisms: usually bacteria are main pathogen → sepsis.
Common gram –ve bacteria → septic shock are (45%) of
cases:
Escherichia coli, klebsiella species, Enterobacter species,
proteus, pseudomonas aeruginosa & Bacteroides fragilis.
Common gram +ve bacteria → r Staphylococcus aureus,
streptococcus pneumonia, streptococcus pyogenes.
Clinical picture:
Septicemia must be suspected in pts ē temp > 38°C or <
36°C & chills.
Tachycardia> 90/min, tachypnea > 20/min, & a
documented infection.
249
Investigations for infection
Aim: to localize site & type of infection & complications.
Lab: urine analysis, cultures (of bl, urine, & sputum)
Radiological: chest x ray, ultrasound abdomen
Inflammatory markers: C- reactive protein &
procalcitonin
Treatment:
Hemodynamic resuscitation, 02 therapy & inotropic
support
Septic shock:
Sepsis (45%) of cases:
enterococcus species &
Sepsis ē multiorgan- system failure (MOF)
hypotension unresponsive to adequate fluid replacement
Even with best TTT, mortality ranges from I5% in patients
ēout to 40-60% in pts ē septic shock.
factors contribute to ↑ incidence of sepsis:
I. Widespread use of corticosteroids &
immunosuppressive drugs for organ transplants &
auto-immune dis.
2. Aggressive cancer chemotherapy & radiation
therapy.

250
3. Longer lives of pts predisposed to sepsis, elderly,
diabetics, cancer pts, pts ē major organ failure & ē
granulocytopenia.
4. ↑ use of invasive devices as surgical prosthesis,
inhalation equipment, intravenous catheter & urinary
catheters.
5. Use of antimicrobial drugs that create conditions of
over growth, & subsequent infection by aggressive,
antimicrobial resistant organism.

251
 Preventive
clinical care
Details about preventive clinical care, will
be given in section about special
epidemiology & occupational medicine.
• AN APPROACH TO APPLYING PREVENTIVE
CARE IN CLINICAL PRACTICE
The following (RISE) is one approach to help you
remember to apply the principles of preventive
medicine in daily clinical practice.
• First identify the particular Risks of this patient;
consider recommended Immunizations (and
chemoprophylaxis); review recommended Screening
with this patient; and address appropriate Education
or counseling.

252
• SYSTEMS OF CARE
Preventive care is improved by its incorporation into
systems of health delivery. Many elements of
prevention do not necessarily need to be provided
directly by the family physician. For example,
reminders can be automatically mailed to patients
when their mammogram or colonoscopy is due.
Office staff can be trained to identify patients
deficient in their recommended preventive care
, ’ r be flagged for
physician review. They can also help implement
screening programs, such as the 5 As, for all patients
who use tobacco. Electronic record systems
particularly allow for more ease of tracking
preventive care than previous paper charts.
However, any system requires flexibility given the
frequent updates and changes in recommendations
that may occur as new evidence of effectiveness
emerges or new technologies become available to
enhance earlier detection.
• Clinical preventive services include:
immunizations, counseling (e.g., to stop smoking),
screening, and chemoprophylaxis (i.e., taking a
medicine to prevent adverse health outcome).
253
• Immunizations are one of the most effective
prevention strategies ever introduced; ANY physician
need to be prepared to address patient and parental
concerns regarding vaccine safety and reasons for
immunizing.
• The goal of screening is not merely to find
problems but rather to identify asymptomatic
persons for whom an intervention will reduce
progression of early disease or prevent an adverse
health event.
•W r chemoprophylaxis strategy
(e.g., aspirin to prevent myocardial infarction), it is
important to balance the potential risk reduction
against the potential for harm.
• ff v f r v v
demonstrated before implementing it widely in
clinical practice. Most prevention interventions also
have the potential for causing harm.

254
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256
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258
259
260
 Glossary
Airborne transmission: Transmission by air of infectious agents
from respiratory secretions.

Asymptomatic infection: Infection that does not display any

clinical symptoms, but may still be capable of transmitting disease.

Carrier: A person or animal that harbours a specific infectious agent

in the absence of clinical disease and serves as a potential source of
infection.

Communicable disease: A disease capable of being transmitted

from an infected person or species to a susceptible host, either
directly or indirectly.

Concurrent disinfection: Immediate disinfection and disposal of

discharges and infective matter all through the course of a disease.

Contact: A person or animal that has associated with an infected

person or animal that might provide an opportunity to acquire the
infection.

Disinfection: Killing of infectious agents outside the body by direct

exposure to chemical or physical agents. High level disinfection
refers to the inactivation of all microorganisms except some
bacterial spores.

Drainage/secretion precautions: Precautions used to prevent

infections transmitted by direct or indirect contact with purulent
material or drainage from an infected body site.

Droplet transmission: Transmission of infectious agents in

droplets from respiratory secretions.

261
Endemic: The constant presence of a disease or infectious agent
within a given geographic area.

Epidemic: The occurrence of a number of cases of a disease (or

condition) in excess of a number expected in a given time and place.
In some instances, a single case will constitute such an unusual
occurrence.

Fomes (plural fomites): An object such as a book, wooden

object, or an article of clothing that is not harmful in itself, but is
able to harbour pathogenic microorganisms and thus may serve as
an agent of transmission of an infection.

Immunity: The protection against infectious disease generated by

immunisation, previous infection or by other nonimmunologic
factors.

Inapparent infection: The presence of infection in a host without

recognisable clinical signs or symptoms.

Incubation period, IP: The time interval between initial contact

with an infectious agent and the appearance of clinical signs and
symptoms.

Infection: Invasion and multiplication of microorganisms in body

tissues.

Infectious agent: An organism that is capable of producing

infection or infectious disease.

Infestation: The lodgement, development and reproduction of

arthropods on the surface of the body of persons or animals or in
clothing.

262
Isolation: Represents separation for the period of communicability,
of infected persons or animals from others in such places and under
such conditions as to prevent or limit the direct or indirect
transmission of the infectious agent. Categories of isolation include:
• strict isolation: for highly contagious infections spread by air and
contact
• contact isolation: for diseases spread primarily by close or direct
contact
• respiratory isolation: to prevent transmission over short
distances through the air.
For drainage/secretion precautions see separate entry. For blood
and body substance precautions, see appendix.

Nosocomial infection: Hospital-acquired infection.

Notifiable disease: Disease or condition that is required by law to

be notified to the Ministry of Health.

Notification: The process of reporting a notifiable infectious

disease.

Period of communicability: The time during which an infectious

agent may be transferred directly or indirectly from an infected
person or animal to a susceptible host.

Personal hygiene: The protective measures within the

responsibility of the individual that limit the spread of infectious
diseases.

Personal protective equipment, PPE: The equipment to be worn

when performing duties that may involve possible occupational
exposure to blood, splashing or aerosols from cleaning processes –
for example, masks, goggles, gloves and aprons.

263
Quarantine: The restriction of freedom of movement of apparently
healthy individuals who have been exposed to infectious disease.

Reservoir of infectious agents: Any person, animal, or substance

in which an infectious agent normally lives and multiplies in such a
manner that it can be transmitted to a susceptible host.

Resistance: The natural ability of an organism to resist micro-

organisms or toxins produced in disease.

School exclusion: Exclusion from school or children’s services

centre under Health (Infectious Diseases) Regulations.

Source of infection: The person, animal or substance from which

an infectious agent passes to a host.

Surveillance: Personal surveillance is the practice of close medical

or other supervision of contacts to permit prompt recognition of
infection or illness but without restricting the movements of the
individual.

Susceptibility: Lack of resistance to a particular pathogenic agent.

Transmission: In terms of infection, it relates to any mechanism by

which an infectious agent is spread from a source or reservoir to a
person. This may be direct or indirect (that is, vehicle-borne, vector-
borne, or airborne).

Standard precautions: Work practices that require everyone to

assume that all blood and body fluids are potential sources of
infection, independent of perceived risk. Such precautions involve
the use of safe work practices and protective barriers, and the safe
disposal of body substances and soiled material. See appendix.

264
Vector: A carrier, especially the animal (usually an arthropod) that
transfers an infective agent from one host to another.

Zoonosis: A disease of animals that may be transmitted to humans

under natural conditions.

265
Appendix 1: Standard and additional precautions
General
Infection control and prevention uses a risk management
approach to minimize or prevent the transmission of infection.
Standard and additional precautions principles and practice are
based on the mode of transmission of an infectious agent.
Standard precautions are work practices required for the basic
level of infection control. They include good hygiene practices,
particularly washing and drying hands before and after patient
contact, the use of protective barriers which may include gloves,
gowns, plastic aprons, masks, eye shields or goggles, appropriate
handling and disposal of sharps and other contaminated or
clinical
(infectious) waste, and use of aseptic techniques.
Standard precautions apply to all patients regardless of their
diagnosis or presumed infection status, and in the handling of:
• blood
• all other body fluids, secretions and excretions (except sweat),
regardless of whether they contain visible blood
• non-intact skin
• mucous membranes (mouth and eyes)
• standard precautions also apply to dried blood and other body
substances, including saliva.
Standard precautions should be considered minimum
requirements for infection control. Implementing standard
precautions minimises the risk of transmission of infection from
person to person even in high-risk situations. Standard
precautions should be implemented at all times particularly when
patients are undergoing invasive procedures, including
catheterisation, cannulation or intubation. Health services that
offer these procedures should provide detailed protocols for
patient management in their infection control manuals.

266
Standard precautions
The use of standard precautions is essential as the primary
strategy for the successful minimisation of transmission of health
care associated infection because:
• infectious patients may not show any signs or symptoms of
infection that may be detected in a routine history and medical
assessment
• a patient’s infectious status is often determined by laboratory
tests that may not be completed in time to provide emergency
care
• patients may be infectious before laboratory tests are positive or
symptoms of disease are recognized (the window period of
disease)
• people may be placed at risk of infection from those who are
asymptomatic but infectious.
Standard precautions for infection control in health care settings
consist of the following work practices:
• aseptic technique for all invasive procedures, including
appropriate use of skin disinfectants
• personal hygiene practices, particularly hand washing and
drying before and after all significant patient contacts
• the use of 70% alcohol-based chlorhexidine (0.5%) hand rub
solutions as an adjunct to hand washing
• use of personal protective equipment, which may include gloves,
impermeable gowns, plastic aprons, masks/face shields and eye
protection
• appropriate handling and disposal of sharps and other clinical
(infectious) waste
• appropriate reprocessing of reusable equipment and
instruments, including appropriate use of disinfectants
• environmental controls, including design and maintenance of
premises, cleaning and spills management including appropriate
use of disinfectants

267
• appropriate provision of services as laundry and food services.

268
Additional precautions
Additional Precautions are used for patients known or suspected
to be infected or colonised with epidemiologically important or
highly transmissible pathogens that can transmit/cause infection
by the following means:
• airborne transmission (e.g. pulmonary tuberculosis, chickenpox,
measles)
• droplet transmission of respiratory secretions (e.g. rubella,
pertussis, influenza)
• contact transmission (direct or indirect) with patients who may
be disseminators of infectious agents of special concern (e.g. the
dry skin of those colonised with Multi-resistant Staphylococcus
aureus [MRSA], faecal contamination from carriers of
vancomycin-resistant enterococci [VRE] or contaminated
surfaces)
• inherent resistance to standard sterilisation procedures or other
disease-specific means of transmission where standard
precautions are not sufficient (e.g. patients with known or
suspected Creutzfeldt-Jakob disease)
• any combination of these routes.
Additional precautions are designed to interrupt transmission of
infection by these routes and should be used, in addition to
standard precautions, when standard precautions alone might not
contain transmission of infection.
Additional precautions may be specific to the situation for which
they are required, or may be combined where microorganisms
have multiple routes of transmission.
Additional precautions should be tailored to the particular
infectious agent involved and the mode of transmission, and may
include one or any combination of the following:
• allocation of a single room with ensuite facilities
• a dedicated toilet (to prevent transmission of infections that are
transmitted primarily by contact with faecal material, such as for
patients with infectious diarrhoea or gastroenteritis caused by

269
enteric bacteria or viruses)
• cohorting (room sharing by people with the same infection) may
be an alternative if single rooms are not available
• special ventilation requirements (e.g. monitored negative air
pressure in relation to surrounding areas)
• additional use of personal protective equipment (e.g. health care
workers attending to patients in respiratory isolation should wear
a well-fitting mask: a 0.3-mm particulate filter mask (P2 or N95
mask) is recommended for tuberculosis)
• rostering of immune health care workers to care for certain
classes of infectious patients (eg chickenpox)
• dedicated patient equipment
• restricted movement of both patients and health care workers.
Additional precautions are not required for patients with
bloodborne viruses, such as HIV, hepatitis B virus or hepatitis C
virus, unless there are complicating infections, such as pulmonary
tuberculosis.
To minimise the exposure time of other people in office practices
or hospital waiting rooms, people identified as ‘at risk’ of
transmitting droplet or airborne diseases (e.g. a child with
suspected chicken pox) should be subject to additional
precautions including isolation and should be attended to before
other people waiting for treatment.
An outline of the application of additional precautions for
infections with airborne, droplet or contact transmission is shown
in the following table.

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271
Handwashing
• Wash and dry hands after touching blood, body fluids,
secretions,
excretions and contaminated items such as equipment or
instruments, regardless of whether gloves are worn or not.
• Wash and dry hands immediately after gloves are removed,
after significant patient contact such as contact with or physical
examination, emptying drainage bags, undertaking venepuncture
or delivery of an injection or going to the toilet.
• Wash and dry hands following any activities that may transfer
microorganisms to other patients or environments.
• Use plain liquid soap for routine hand washing. Antimicrobial
liquid soap solutions are required for invasive procedures and in
some situations such as those patients with VRE and MRSA.
• A 70% alcohol-based chlorhexidine (0.5%) hand rub solution
may be used as an adjunct to handwashing and in situations
where water is not readily available.

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 Steps for proper handwashing

Personal protective equipment

The use of personal protective equipment (PPE) protects the
health care worker and others from exposure to blood and body
fluids/substances. PPE that complies with relevant Standards
should be readily available and accessible in all health services.

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Gloves
• Wear gloves (clean non sterile gloves are adequate) when
touching blood, body fluids, secretions, excretions and
contaminated items; put on clean gloves just before touching
mucous membrane and non-intact skin. Sterile gloves are
required for invasive procedures.
• Change gloves between tasks and procedures on the same
patient after contact with material that may contain a high
concentration of
microorganisms.
• Remove gloves promptly after use, before touching non-
contaminated items and environmental surfaces and before going
to another patient.
Dispose of gloves in the clinical (infectious) waste or place in a
plastic bag and tie before disposing of it in the general household
waste.
• Wash and dry hands immediately after removing gloves to avoid
transfer of microorganisms to other patients or environments.

Gowns
• Wear a gown (a clean non-sterile gown is adequate) to protect
skin and prevent soiling of clothing during procedures and patient
care activities that are likely to generate splashing or sprays of
blood, body fluids, secretions, or excretions or cause soiling of
clothing.
• Select a gown (long- or short –sleeved) that is appropriate for
the activity and the amount of fluid likely to be encountered.
• Remove the used gown as promptly as possible using gloved
hands, roll up carefully and place in a linen receptacle for
laundering.

274
• Wash and dry hands to avoid transfer of microorganisms to
other patients and environments.

Masks, eye protection, face-shields

Wear a mask and eye protection or a face-shield to protect
mucous membranes of the eyes, nose and mouth:
• during procedures and patient-care activities that are likely to
generate splashes or sprays of blood, body fluids, secretions and
excretions
• during cleaning activities. Remove the mask by holding the ties
only and dispose of the mask into a clinical waste bin.
Reusable face shields or goggles should be removed carefully
and placed in a receptacle for cleaning.

Waterproof aprons
Wear waterproof aprons when splashes or sprays of blood or
body fluids/ substances are likely such as during cleaning
activities.
Remove the used apron as promptly as possible using gloved
hands, roll up carefully and place in a clinical waste bin.

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Environmental control
Ensure that the health service has adequate procedures for the
routine care, cleaning, and disinfection of environmental surfaces,
beds, bedrails, bedside equipment, and other frequently touched
surfaces and that these procedures are being followed. See
Appendix for cleaning and waste disposal.

276
Appendix 2: Procedure for managing an exposure to
blood/body fluids/substances
These include sharps injuries (including needlestick) and splashes
into/onto mucous membranes or bare intact skin.
Occupational hazards for health care workers from sharps
injuries (including needlestick injury) and other blood or body fluid
incidents include human immunodeficiency virus (HIV), hepatitis B
virus (HBV) and hepatitis C virus.
Exposure is an injury that involves direct skin contact with a body
fluid listed above and there is compromised skin integrity such as an
open wound, abrasion or dermatitis, or if there is direct mucous
membrane contact. For exposure to skin, the larger the area of skin
exposed and the longer the time of contact, the more important it is
to verify that all the relevant skin area is intact.

Exposure to blood and body fluids/substances

The following body fluids pose a risk for bloodborne virus
transmission:
• blood, serum, plasma and all biological fluids visibly contaminated
with blood
• laboratory specimens that contain concentrated virus
• pleural, amniotic, pericardial, peritoneal, synovial and
cerebrospinal fluids
• uterine/vaginal secretions or semen.

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Infection control protocols
All health services must develop their own infection control
protocols for communicable diseases, including clear written
instructions on the appropriate action to take in the event of an
exposure to blood or body fluids/substances including needlestick
injuries and other blood or body fluid incidents involving either
patients or health care workers, including:
• the physician, medical officer or other suitably qualified
professional to be contacted
• the laboratory which will process emergency specimens
• the pharmacy which stocks prophylactic medication
• procedures for investigating the circumstances of the incident and
measures to prevent recurrence (this may include changes to work
practices, changes to equipment, and/or training)
• details for prompt reporting, evaluation, counselling, treatment
and follow-up of occupational exposures to bloodborne viruses.

Immediate action
Treatment protocols should include removal of contaminated
clothing and thorough washing of the injured area with soap and
water. Affected mucous membranes should be flushed with large
amounts of water. Eyes should be flushed gently.
The exposed person must report any occupational exposures
immediately.
The exposed person should have a medical evaluation, including
information about medications they are taking and underlying
medical conditions or circumstances. Postexposure prophylaxis
(PEP and N-PEP) and counselling should be available and offered.
Treatment should be available during all working hours, and on call
after hours (e.g., through an on-call infectious diseases physician).
Patients or others exposed to blood or other body fluids/substances
must be informed of the exposure by a designated professional,
278
while maintaining confidentiality about the source of the blood.
Baseline serum should be collected from the patient and expert
counselling provided on the implications of what has happened.
Postexposure prophylaxis (PEP and NPEP) and appropriate long-
term follow-up should be offered where applicable.
Patient or source refusal for testing and serum storage should be
documented.
Document the incident and include:
• date, time and type of exposure
• how the incident occurred
• name of the source individual (if known)
Exposure incidents that do not occur in a health service should be
reported to a general medical practitioner or the Emergency
Department at the nearest hospital.

Management of the source individual

The person whose blood or body fluids are the source of an
occupational/non-occupational exposure or other injury should be
evaluated for infection with HIV, HBV and HCV. Information
available in the medical record or from the source person may
suggest or rule out infection with each virus. If the source is known
to have HIV infection, then information on stage of infection and
current and previous antiretroviral therapy should be gathered and
used in deciding the most appropriate regimen of post exposure
prophylaxis (PEP).
If the HIV, HBV or HCV status of the source person is unknown, then
the source person should be informed of the incident, and their
consent sought to test for these viruses, with appropriate pre and
post-test counselling. Their consent to having the information in
their patient record used should be sought also. If consent cannot be
obtained, for example if the patient is unconscious or unwilling to
consent, then procedures should be followed which comply with
legislation.
279
The source individual should be tested as follows at the time of injury:
• HIV antibody
• HBsAg
• HCV antibody.
If the HCV antibody test is positive, then HCV polymerase chain
reaction (PCR) should be performed to test for HCV
RNA.
Transmission is much less likely to occur from a source who is PCR
negative. The status of the source individual may be known at the
time of the incident. In this case the affected person should be
managed as described below under ‘immediate management’. If the
source is unknown, the case should be managed as described below.

Source individual unknown

Reasonable efforts should be made to identify the source. If the
source remains unknown, appropriate follow-up should be
determined on an individual basis depending on:
• the type of exposure
• the likelihood of the source being positive for a blood pathogen
• the prevalence of HIV, HBV and HCV in the community of the likely
source on whom the instrument or needle was used.

Management of the exposed person

Immediate care of the exposure site Contaminated clothing should
be removed, and the injured area should be washed well with soap
and water (an antiseptic could also be applied). Any affected mucous
membranes should be flushed with large amounts of water. If the
eyes are contaminated, they should be rinsed gently but thoroughly
with water or normal saline, while kept open.
Evaluation of the exposure The exposed person should be examined
to confirm the nature of exposure and counselled about the

280
possibility of transmission of bloodborne disease.

Evaluation and testing of the exposed person

The exposed person should have a medical evaluation, including
information about medications they are taking and underlying
medical conditions or circumstances. All exposed people should be
assessed to determine the risk of tetanus.
Depending on the circumstances of the exposure, the following may
need to be considered:
• tetanus immunoglobulin
• a course of adsorbed diphtheria tetanus vaccine, adult formulation
(Td) vaccine
• Td booster.
The exposed person would normally be tested for HIV antibody,
HCV antibody and antibody to HBV surface antigen (HBsAg) at the
time of the injury, to establish their serostatus at the time of the
exposure. Expert counselling on the implications of the event, PEP
(post exposure prophylaxis) and appropriate long-term follow-up
should be offered.
An option that may be offered to health care workers who do not
wish to undergo testing at the time of the exposure is to have blood
collected and stored but not tested. Blood that is collected and
stored for this purpose must be retained for a minimum period of 12
months.
If the source person is found to be HIV, HBV and HCV negative, no
further followup of the exposed person is generally necessary,
unless there is reason to suspect the source person is
seroconverting to one of these viruses, or was at high risk of
bloodborne viral infection at the time of the exposure. If source is
positive for one of these viruses, pregnancy testing should be
offered to women of child-bearing age who have been exposed and
whose pregnancy status is unknown.

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Postexposure counselling
A specialist with knowledge of bloodborne infections should
undertake follow-up. If it is demonstrated that a person has been
exposed to a bloodborne pathogen, they should not donate blood,
semen, organs or tissue for six months, and should not share
implements that may be contaminated with even a small amount of
blood (e.g., razors or toothbrushes).
For HIV and HBV, they should be informed of the risk of
transmission to sexual and injecting partners for a sixmonth period,
and be counselled about issues of safe sex and safe injecting. If PEP
is indicated, or there is a risk of acute infection with HIV, HCV or
HBV, advice should be offered on pregnancy and breastfeeding
based on an individual risk assessment. In the case of HIV, patients
should be advised of the remote risk of seroconversion up to 12
months post-exposure, particularly if specific PEP was undertaken.

282
283
Appendix 3: Procedure for managing spills of
blood and body fluids/substances
Health services should have management systems in place for
dealing with blood and body substance spills and protocols should
be included in procedural manuals and emphasised in ongoing
education or training programs.
The basic principles of blood and body fluid/substance spills
management are:
• standard precautions apply, including use of personal protective
equipment (PPE) as applicable
• spills should be cleared up before the area is cleaned (adding
cleaning liquids to spills increases the size of the spill and should be
avoided)
• generation of aerosols from spilled material should be avoided.
Using these basic principles, the management of spills should be
flexible enough to cope with different types of spills, taking into
account the following factors:
• the nature (type) of the spill (e.g. sputum, vomit, faeces, urine,
blood or laboratory culture)
• the pathogens most likely to be involved in these different types of
spills (e.g. stool samples may contain viruses, bacteria or protozoan
pathogens whereas sputum may contain Mycobacterium
tuberculosis)
• the size of the spill (e.g. spot [few drops], small [<10cm] or large
[>10cm])
• the type of surface (e.g. carpet or impervious flooring)
• the location involved i.e. whether the spill occurs in a contained
area such as a microbiology laboratory or in a public or clinical area
of a health service, in a public location or within a community
premises
• whether there is any likelihood of bare skin contact with the soiled
(contaminated) surface.

284
Equipment
Standard cleaning equipment, including a mop and cleaning bucket
and cleaning agents, should be readily available for spills
management and should be stored in an area known to all. This is
particularly important in clinical areas. To facilitate the
management of spills in areas where cleaning materials may not be
readily available, a disposable ‘spills kit’ could be used, containing
the following items:
• a large (10 L) reusable plastic container or bucket with fitted lid,
containing the following items
• appropriate leak proof bags and containers for disposal of waste
material
• a designated, sturdy scraper and pan for spills (similar to a ‘pooper
scooper’)
• about five sachets of a granular formulation containing 10,000
ppm available chlorine or equivalent (each sachet should contain
sufficient granules to cover a 10-cm diameter spill)
• disposable rubber gloves suitable for cleaning (vinyl gloves are not
recommended for handling blood)
• eye protection (disposable or reusable)
• a plastic apron
• a respiratory protection device (for protection against inhalation
of powder from the disinfectant granules, or aerosols, which may be
generated from high-risk spills during the cleaning process).
Single-use items in the spills kit should be replaced after each use of
the spills kit.
With all spills management protocols, it is essential that the affected
area is left clean and dry.
Sodium hydroxide (caustic soda) spills kits should be available for
areas at risk for higher-risk CJD spills, such as neurosurgery units,
mortuaries and laboratories.

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Procedures
In clinical areas blood and body fluid/substance spills should be
dealt with as soon as possible. In operating rooms, or in
circumstances where medical procedures are under way, spills
should be attended to as soon as it is safe to do so.
Care should be taken to thoroughly clean and dry areas where there
is any possibility of bare skin contact with the surface (e.g. on an
examination couch).
Personal protective equipment (PPE) should be used for all cleaning
procedures and disposed of or sent for cleaning after use. Hands
should be washed and dried after cleaning.
Where a spill occurs on a carpet, shampoo as soon as possible. Do
not use disinfectant. Steam cleaning may be used instead.
Wash hands thoroughly after cleaning is completed.
Spots or small spills Spots or drops of blood or other small spills (up
to 10cms) can easily be managed by wiping the area immediately
with paper towelling and then cleaning with warm water and
detergent followed by rinsing and drying the area. Dry the area as
wet areas attract contaminants.
A hospital grade disinfectant can be used on the spill area after
cleaning.
Large spills Where large spills (over 10cms) have occurred in a ‘wet’
area, such as a bathroom or toilet area, the spill should be carefully
washed off into the sewerage system using copious amounts of
water and the area flushed with warm water and detergent.
Large blood spills that have occurred in ‘dry’ areas (such as clinical
areas) should be contained and generation of aerosols should be
avoided.
Granular formulations that produce high available chlorine
concentrations can contain the spilled material and are useful for
preventing aerosols. A scraper and pan should be used to remove
the absorbed material. The area of the spill should then be cleaned
with a mop and bucket of warm water and detergent. The bucket
and mop should be thoroughly cleaned after use and stored dry.

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Use of sodium hypochlorite (bleach) It is generally unnecessary to
use sodium hypochlorite for managing spills but it may be used in
specific circumstances.
It is recognised, however, that some health care workers/members
of the public may feel more reassured that the risk of infection is
reduced if sodium hypochlorite is used. Health care workers and
members of the public should be aware that there is no evidence of
benefit from an infection control perspective.
Hypochlorites are corrosive to metals and must be rinsed off after
10 minutes and the area dried.

Creutzfeldt–Jakob disease (CJD)

If a spill of tissue (potentially) infected with Creutzfeldt–Jakob
disease (CJD) occurs (eg brain tissue), the contaminated item should
either be destroyed by incineration or immersed in either sodium
hydroxide or sodium hypochlorite for one hour, rinsed and placed in
a pan of clean water and sterilised on an eighteen minute cycle.
The items should then be cleaned following routine cleaning and
sterilisation procedures.
Surface spills should be cleaned up using paper towels before the
surface is wiped over with either sodium hydroxide or sodium
hypochlorite, left for one hour (if possible or as long as possible,
with the area cordoned off), the solution wiped off and the surface
cleaned by following routine cleaning procedures.

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Appendix 4: Cleaning and waste disposal
procedures Cleaning
General
Cleaning is important particularly in work areas because deposits
of dust, soil and microbes on surfaces can transmit infection.
Contaminated areas such as operating rooms or isolation rooms
must be cleaned after each session and spot cleaned after each
case or thoroughly cleaned as necessary.
The following basic principles should be followed:
• written cleaning protocols should be prepared, including
methods and frequency of cleaning. These should include policies
for the supply of all cleaning and disinfectant products
• standard precautions (including wearing of personal protective
equipment as applicable) should be implemented when cleaning
surfaces and facilities
• cleaning methods should avoid generation of aerosols
• all cleaning items should be changed after each use and
cleaned and dried before being used again. They should also be
changed immediately following the cleaning of blood or body
fluid/substance spills, cleaned and dried. Single use cleaning
items are preferred where possible such as cleaning cloths which
should be lint free
• sprays should not be used as they can become contaminated
and are difficult to clean. Sprays are not effective as they do not
touch all parts of the surface to be cleaned
• detergents should not be mixed with other chemicals
• all cleaning solutions should be prepared fresh before use.
• Floors in hospitals and day care facilities should be cleaned
daily, or as necessary, with a vacuum cleaner fitted with a
particulate-retaining filter, which should be changed in
accordance with the manufacturer’s instructions.

288
• The exhaust air should be directed away from the floor to avoid
dust dispersal.
• A ducted vacuum cleaning system can also be used, as long as
safe venting of the exhaust air is ensured.
• Damp dusting is essential using a lint free cloth. Brooms
disperse dust and bacteria into the air and should not be used in
patient/clinical areas. Dust retaining mops, which are specially
treated or manufactured to attract and retain dust particles, do not
increase airborne counts as much as ordinary brooms and
remove more dust from surfaces. However, brooms and dust-
retaining mops
should not be used in clinical areas where there is a high risk of
infection associated with dust (e.g., burns units).
Procedure for routine surface cleaning
• All cleaning solutions should be prepared immediately prior to
use.
• Work surfaces should be cleaned (wiped over) with a neutral
detergent and warm water solution, rinsed and dried before, and
after, each session or when visibly soiled. Spills should be
cleaned up as soon as practical.
• When a disinfectant is required for surface cleaning, the
manufacturer’s recommendations for use and OH&S instructions
should be followed.
• Buckets should be emptied after use, washed with detergent
and warm water, rinsed in hot water and stored dry - turn upside
down.
• Mops should be laundered or cleaned in detergent and warm
water, rinsed in hot water then stored dry. Mop heads should be
detachable or stored with mop head uppermost.
Specialised areas
• Isolation rooms and ensuite bathrooms should be cleaned at
least twice daily dependant on the type of organism.
• Operating rooms and day procedure rooms including endoscopy
rooms should be cleaned after each operating session and when
visibly soiled.
289
Thorough cleaning of the operating suite should be performed
daily in addition to the cleaning performed after each operating
session.
• Obstetric areas, particularly delivery suites should be cleaned
after each delivery, when visibly soiled and at least daily.
• Oncology areas should be cleaned twice daily.
• Sterilising processing departments (SSDs) should be cleaned at
least twice daily and when visibly soiled.
Wet areas
Toilets, sinks, washbasins, baths, shower cubicles, all fittings
attached to showers, baths and hand basins and surrounding
floor and wall areas should be cleaned at least daily and more
frequently as required.
Walls and fittings
Walls and screens should be cleaned quarterly or if visibly soiled.
Blinds and curtains should be cleaned quarterly or if visibly soiled.
Carpets should be vacuumed daily and other floor surfaces
washed daily and when soiled.
Bed and examination screens should be changed weekly and
when visibly soiled.
Cleaning for Creutzfeldt-Jakob disease
infectious agents
Spills of central nervous system tissue or cerebrospinal fluid
should be absorbed onto paper towels and disposed of by
incineration. The surface should then be soaked with 1 molar
sodium hydroxide or
2.0-2.5% sodium hypochlorite, left for one hour and cleaned again
with paper towels that are disposed of by incineration.
Spills of blood or other body fluids and tissues should be cleaned
using standard spills management procedures. Personal
protective equipment used when cleaning contaminated surfaces
should be incinerated after use. Reusable eye protection should
be cleaned as above.

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Maintenance of cleaning equipment
• Cleaning items (including solutions, water, buckets, cleaning
cloths and mop heads) should be changed after each use. They
should also be changed immediately following the cleaning of
blood or body substance spills.
• These items should be washed in detergent and warm water,
rinsed and stored dry between uses. Mops with detachable heads
should be laundered between uses.
Spills of laboratory cultures of human
pathogens
Spills of laboratory cultures should be absorbed on to paper
towels and disposed of as clinical waste. The contaminated
surfaces should be treated with 2.0-2.5% sodium hypochlorite, left
for one hour and cleaned again with paper towels that are
disposed of as clinical waste.

Waste disposal
General
All health care facilities should have policies and procedures in
place for the correct management of all waste generated. The
Environmental Protection Authority (EPA) has clear guidelines on
how waste should be managed. Waste is classified into 3 main
groups of waste:
• general
• clinical
• pharmaceutical
All waste should be stored in secure areas until collected. Waste
disposal companies licensed with the EPA will collect all clinical
and pharmaceutical waste for disposal in specialised waste
disposal facilities.
Waste should be removed from clinical areas at least three times
each day and more frequently as needed such as from
specialised areas. Waste bags should be tied before removing

291
from the area.

General waste Place in general waste bin for removal.

Clinical waste Place in biohazard bags as soon as possible.
Biohazard bags have a biohazard symbol and are currently
coloured yellow.
Single use sharps should be placed (by the user) into a sharps
container that meets the Standards
Pharmaceutical waste
When uncertain about how to dispose of leftover pharmaceuticals
they should be returned to pharmacy for correct
disposal.
Most disinfectants can be disposed of through the sewer system
by running cold water into the sink prior to pouring the disinfectant
into the sink. Leaving the cold water running for a few moments
after the disinfectant has been disposed of as this dilutes the
disinfectant.

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Appendix 5: Infections in
children’s services centres
Children in day care centres and other children’s services centres
and kindergartens are particularly at risk of developing
communicable diseases because of:
• Close contact with other children and staff
• Lack of previous exposure to common infections
• Lack of toilet training
• Lack of control of other body secretions
• Mouthing behaviour These risk factors may be increased when
staff are not appropriately trained, group sizes are large, and mixing
of age groups occurs.
Infections with the following organisms have been shown to be
more common in these settings, or have been reported as epidemic:
• Respiratory Syncytial virus (RSV)
• Influenza virus
• Haemophilus influenzae type b
• Neisseria meningitidis
• Shigella spp
• Rotavirus
• Giardia lamblia
• Cryptosporidium
• Hepatitis A
• E. coli
• Campylobacter spp
• Parvovirus B19 (erythema infectiosum)
• Coxsackievirus group A (hand, food
and mouth disease)
• Streptococcus, pyogenes,
Staphylococcus aureus (impetigo)
• Cytomegalovirus

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• Scabies
• Head lice

294
Appendix 6: School exclusion table
The following table indicates the minimum period of exclusion from
schools and children’s service centres required for infectious
diseases cases and co. In this Schedule ‘medical certificate’ means a
certificate of a registered medical practitioner.

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296
297
Exclusion cases and contacts is not required for:
Cytomegalovirus Infection, Glandualr fever
(mononucleosis), Hepatitis B or C, Hookworm,
Cytofalovirus Infection, Molluscum contafiosum, or,
Parvovirus (erythema infectiosum, fifth disease).

298
SUMMARY OF INFECTION CONTROL MEASURES

299
300
301
302
303
Actions to Prevent or Slow Antimicrobial Resistance
Antimicrobial resistance can be addressed only through
concerted and collaborative
efforts. To combat the threat posed by antibiotic
resistance, the CDC has identified 4 core
actions that must be taken:
1. Prevent infections and prevent the spread of
resistance. Antimicrobial resistant infections can be
prevented by immunization, infection prevention in
health
care settings, safe food preparation and handling, and
handwashing.
2. Track antibiotic resistant infections. The CDC
gathers data on antimicrobial resistant infections to help
inform strategies and interventions for prevention.
3. Improve antimicrobial use and promote
antimicrobial stewardship. The
most important action is to modify the way antimicrobial
agents are used in humans
and animals. Inappropriate use of antimicrobial agents
is common in hospitalized
patients and often is a result of errors in dosing or
duration of therapy. Unnecessary
exposure to antimicrobial agents results in adverse drug
reactions, complications
including C difficile infections, and subsequent treatment
challenges related to the development of antimicrobial
resistance. Every hospital should have a formal
antimicrobial
304
stewardship program built on validated core elements.
4. Develop drugs and improved diagnostic tests.
Antibiotic resistance develops as a part of a natural
process in which bacteria evolve. Therefore, discovery
of
new antimicrobial agents is needed to keep pace with
the emergence of resistance.
Unfortunately, the number of antimicrobial agents in
late-phase clinical development
is low; in particular, few agents are being developed
with a new mechanism of action
to treat resistant gram-negative infections. Additionally,
new diagnostic tests are needed
to track the development of resistance.

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307
 Table of contents

SERIAL SUBJECT PAGE

OBJECTIVES 7
DEFINTIONS: HEALTH, WELL BEING, QUALTY 9
OF LIFE, HYGIENE, PREVENTIVE MEDICINE,
COMMUNITY, PUBLIC HEALTH,

Factors affecting health of community 16

What is community diagnosis 22
Social medicine 23
Uses of epidemiology 24
SURVEILLANCE = observation 25
Interpretation of surveillance 27
Using Judgment in Analysis 29
Principles of infectious disease ‫هام‬ 31
Epidemiology, General Terms & Definitions
Epidemiologic “Chain” of Infection 35
Correspondence between portal of exit, 37
mode of transmission & portal of entry
Agent 39
Reservoir & Immediate Source of 42
Agent
Characters of Agent Producing Infection & 44
Disease
Attack rate 45
Host factors 46

308
 Herd Immunity 48
serial Subject Page
Herd immunity (again) ‫هام‬ 49
Factors Affecting Process of Infection 52
as a Result of Interaction Between Agent &
Host
Incubation Period 52
Latent period 56
Biological Gradient (Gradient of Infection) 57
Channels of Transmission 58
Direct Modes of Transmission 61
Indirect mode of transmission 63
Nosocomial infection 66
Outbreaks 69
Epidemiological surveillance 73
General prevention & control measures 79
Natural history of disease ‫هام‬ 82
Control measures 83
Chemoprophylaxis ‫هام‬ 84
Disinfection 89
Investigation of an epidemic disease ‫هام‬ 92
Prevention & control of an epidemic disease 97
‫هام‬
Immunization ‫هام‬ 102
Immunity 109
Types of immune response ‫هام‬ 111
Immune response to vaccination ‫هام‬ 112
Types of vaccines 113

309
 Future trends of vaccines 118
Serial Subject Page
Prevention offers greatest promise of 120
reducing cancer mortality due to
viruses
Rules for Vaccinating Certain 122
Populations
Contraindications to Vaccines 124
Human immunoglobulins & non-human 127
antisera
Future trends in vaccines 131
Vaccine as immunotherapy 132
Web resources for vaccine information 133
General guidelines for VAC administration 134
Cold chain & storage of vaccines 143
International vaccination requirements 155
Recommended Pre-exposure Prophylaxis 158
for International Travel & Postexposure
Immunoprophylaxis
Immunization in Special Circumstances 160
Medical management of vaccine reactions 163
in children & adults
Vaccinations in adolescents 168
Japanese encephalitis vaccine 169
Clinic for Vaccine Administration 170
Special considerations in immunization 183
Some clinical issues in infection 191
310
Serial Subject Page
Major manifestations of infection, practical 192
look
History taking in infection 196
Examination in infection 202
FEVER 214
CONTROL OF FEVER 222
Patterns of fever 225
DD of fever 228
MANAGEMENT OF NEW ONSET FEVER IN 233
HOSPITALIZED PATIENT
FEVER OF UNKNOWON ORIGIN 238
Bacteremia, septicemia, septic shock 249
Preventive clinical care 252
Glossary 261
Appendix 1: Standard and additional 266
precautions
Appendix 2: Procedure for managing an 277
exposure to blood/body fluids/substances
Appendix 3: Procedure for managing spills 284
of blood and body fluids/substances
Appendix 4: Cleaning and waste 288
disposal procedures Cleaning
Appendix 5: Infections in children’s 293
services centre
Appendix 6: School exclusion table 295
SUMMARY OF INFECTION CONTROL 299
MEASURES

311
 Actions to Prevent or Slow 304
Antimicrobial Resistance
LIST OF FIGURES & TABLES
SERIAL TITLE PAGE
INTERCONNECTIONS OF HEALTH 13
DETERMINANTS
FACTORS AFFECTING HEALTH OF COMMUNITY 16
USES OF EPIDEMIOLOGY 24
SURVEILLANCE STEPS 25
Steps of epidemiological investigation 26
Global distribution of selected human 35
pathogens
The chain of infection 36
Correspondence between portal of exit, mode 37
of transmission & portal of entry
Epidemiological triad 38
Gram positive bacteria 39
Gram negative bacteria 40
Classification of viruses 41
The principles of herd immunity 50
Differences between intrinsic & extrinsic 55
incubation period
Mechanism of transmission 59
Modes of transmission of viral diseases 60
Vertical & horizontal transmission of infection 62
Common nosocomial agents 67
Phases of an outbreak 72
Late detection & early detection response 74
312
 Key steps in responding for an outbreak 77
Top ten achievements in public health 78
Serial Title Page
Factors that favour eradicability of infectious 78
diseases
Levels of prevention 80
Concepts of disease causation & possible 81
approaches to prevention, natural history of
disease
Prevention paradox 81
Examples of chemoprevention 85
Antimicrobial prophylaxis in surgery 85
Different types of epidemic curves 94
Geographical distribution 95
’ defenses against disease causing 103
pathogens
The cell mediated immune response 105
Types of immunity (summary) 109
Types of immune defenses 110
Comparison between active & passive 110
immunity
Vaccines commonly used for travel 115
Strains commonly used for vaccines 116
Specific groups benefitting from vaccines 117
Recommended pre-exposure prophylaxis for 119
international travel & post immunoprophylaxis
Immunization schedule in Egypt 125

313
Proportion of Egyptian children 18-29 months 126
who are fully immunized
Human immunoglobulins 127

Non-human antisera 127

Immune globulin preparations made from 128
human plasma
Indications & dosage of IM immune globulins 129
in infectious diseases
Needed vaccines 130
Some common misconceptions about vaccines 139
Recommended child & adolescent schedule 140
vaccination by medical indication
Recommended adult immunization schedule by 141
medical condition & other indications
Summary guide to tetanus prophylaxis in routine 142
wound management
Cold chain & storage of vaccines 143
Recommended storage temperatures 149
Summary of some important vaccines 150-
154
Validity of international vaccination certificate 156
Recommended Pre-exposure Prophylaxis for 158
International Travel & Postexposure
Immunoprophylaxis
Vaccines commonly used for international 159
travel
Vaccination recommended in HIV 161
symptomatic & asymptomatic children

314
Vaccination schedule in an unimmunized child 162
Medical management of vaccine reactions in 163
children & adults

Vaccinations in adolescents 168

Major manifestations in infection 202
Summary of clinical picture & 203
management of infection
Linking symptoms elicited from patient 204
history to infection diagnoses
Linking examination findings to infection 208
diagnosis
Components of infection diagnosis & how 209
& why these are ascertained
Infections commonly associated with rash 210
General investigations & possible causes 211
in suspected infections
Specimens & indications for microscopy, 212
culture & other microbiological tests
Patterns of fever 225
Causes of hyperthermia syndromes 226
Comparison between hyperpyrexia & 227
hyperthermia
DD of fever 228
Fever & hepatomegaly, splenomegaly or 230
hepatosplenomegaly

315
 Chronic fever (>14 days) 231

Serial Subject Page

Recommended initial investigations in 232
returning travelers with undifferentiated
fever
Pyrexia of unknown origin 238
Definition of fever of unknown origin 239
Infectious causes of fever of unknown 240
origin
Drugs causing fever of unknown origin 241
Preliminary tests for fever of unknown 247
origin
Factious fever 248
Well adult preventive services 255
Wash your hands 273
Management of exposure to blood/body 283
fluids, summary table
Summary of infection control measures 299
Strategies for optimizing antimicrobial use 303
in hospitals
Instructions for collection & transport of 306
specimens for culture

316
317
‫الحمد هلل‬

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