Power college

Clinical nursing level four student

Course title-communicable disease and neglected
tropical disease2017 E.C
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LO2. Assess, screen and manage common communicable diseases

1. Feco-oral transmitted Diseases

2. Air borne or direct contact
communicable diseases
3. Arthropod borne (intermediate host
borne)
4. Sexually transmitted infections
5. Zoonotic diseases
6. Food borne diseases
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 2.1, Feco-oral transmitted Diseases
• Infectious agents are excreted in the stool of
infected person and,The portal of entry is mouth.
• Fecal oral transmission occurs mostly through
unapparent fecal contamination of food, water
and hands.
• The 5 F’s plays an important role in the
transmission of these diseases.
• In feco - oral transmission of disease food takes a
central position b/c it can be directly or indirectly
contaminated, via polluted water, dirty hands,
contaminated soil or flies
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Classification of feco –oral diseases
• As a result of fecally contaminated water
&food
• As a result of fecally contaminated soil
• As a direct contact with feces

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 Water (fluid)

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Feces Soil Food
Mouth

Flies

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Fomites

Finger

Fig. 2.1 The five “Fs” which play an important role in fecal oral diseases
transmission (finger, flies, food, fomites and fluid).

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 2.1.1. Typhoid Fever
Definition-A systemic infectious disease
characterized by high continuous fever,

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malaise and involvement of lymphoid

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tissues , spleen and endothelial tissue.

Infectious agent -Salmonella typhi

Reservoir -Humans the only
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Epidemiology
• Annual incidence is estimated at about 22
million cases with approximately 200,000

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deaths worldwide.particularly in poor ecnomical

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status

• However, its real impact is difficult to estimate

because the clinical picture is confused with
those of many other febrile infections. 7
Mode of transmision
• By water and food contaminated by feces of
carriers.Flies may infect foods in which the

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organisms then multiply to achieve an infective dose.

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Incubation period
• Varied based on inoculum size and host’s health and
immune status, but usually 1-3 weeks that can be wide as
3- 60 days
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 Period of communicability
• As long as the bacilli appear in excreta,

• Usually from the 1st week throughout

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convalescence.

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• About 10% of untreated pts will discharge bacilli
for 3 months after onset of symptoms, and

• 2%-5% become chronic carriers.

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Susceptibility and resistance

• General

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• Decrease stomach acidity (Gastric achlorhydria)

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• Loss intestinal integrity

• HIV positive

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Pathogenesis
• Depends on a number of factors including the
infecting species and infectious dose.

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• Ingested organisms survive exposure to gastric

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acid before gaining access to the small bowel.

• The organism enters the gastrointestinal tract

and invades the mucosa of colon and ileum.
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After intracellular multiplication in the
mucosal cells, bacteremia will occur.

 Tissue invasion causes inflammation in the

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intestine and gall bladder.

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Hematogenous dissemination occurs to spleen,
liver and bone marrow.

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Clinical manifestations
The Severity of the illness may range from mild, brief illness,
to acute severe disease with central nervous system

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involvement and death.
First weak Abdominal pain

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Mild illness like:
Lethargy
Fever-daily
Malaise and
increase in
stepladder ways Head ache

Anorexia diarrhea 13
Second week • Feces may contain

• Fever continuous blood

• Severe illness with • Splenomegaly

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• Weakness, confusion • Rose spots-pink
papules on the upper
• Mental dullness or

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abdomen and lower
delirium
chest -result of bacterial
• Abdominal discomfort
embolization .
and distention
• Diarrhea 14
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“Rose spot”, the rash of enteric
fever due to S. typhi or S. 15

paratyphi
Third week
• Pt continues to be febrile & increasingly exhausted

• The patient goes to a pattern of “typhoidal state"

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characterized by extreme toxemia, disorientation

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• Intestinal perforation and hemorrhage.
• If no complications occur:

• Begins to improve .
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• Temperature decreases gradually.
C/M for suggestive of typhoid fever are:
• Headache, • Rose spots

• Joint pain • Relative

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• Back pain bradycardia

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• Abdominal • leukopenia

discomfort

• Fever 17
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 Complication
It accounts 30% untreated case and accounts for
75% of all death.

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GI perforation and hemorrhage

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Meningitis

Arthritis, osteomyelitis

Nephritis

Myocarditis 19
Diagnosis
• Based on clinical ground

• Culture( blood, bone marrow ,Stool and urine)

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• Widal test O and H Ags - commonly

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Treatment-
Symptomatic treatment:

• Use of antipyretics, e.g., paracetamol to control fever.

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First line
Ciprofloxacin, 500mg P.O., BID for 10-14 days
Alternative
Amoxicillin,1g, P.O.,QID., for children: 20 – 40mg/kg/day

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P.O., in 3 divided doses for 14 days OR

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Chloramphenicol, 500mg P.O., QID, for 14 days: For
children: 25mg/kg. OR
 Sulfamethoxazole+trimethoprim, 800mg/160mg P.O., BID
for 14 days. For children 6 weeks– 5 months, 100/20mg; 6
months – 5 yrs, 200/40mg; 6 – 12 yrs, 400/80mg BID…… 21
For severe cases :

Ceftriaxone, 1g QD as a single dose OR in 2 divided

doses I.M. OR I.V. for 7-10 days. OR

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Chloramphenicol, 1g, IV bolus QID until 48 hrs after

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fever has settled, followed by 500mg P.O., QID for a total
of 14 days. For children: 25mg/kg, IV bolus QID, until 48
hrs after fever has settled, followed by 25mg/kg P.O.,
QID for a total of 14 days.
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Prevention and control
• Treatment of patients and carriers

• Education

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• Sanitary disposal of feces and control flies

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• Provision of safe and adequate water

• Safe handling of food

• Exclusion of typhoid carriers and patients.

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• Regular check-up of food handlers
 2.1.2 Bacillary dysentery
Definition
• An acute bacterial infectious disease involving the large

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and distal small intestine, caused by the bacteria of
genus shigella which invade and dest

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Reservoir -Humans
Period of communicability
• During acute infection and until the infectious agent is
no longer present in feces, usually within four weeks
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after illness
Infectious agent
 Shigella -gram negative, non-motile bacteria
Comprised of four species or serotypes

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• Group A= Shigella dysentriae

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• Group B= Shigella flexeneri
• Group C= Shigella boydii
• Group D= Shigella sonnei
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• destroys the intestinal epithelium.
 Mode of transmission
• Similar with typhoid fever but .Only a very
small dose is required less than 200 (even

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10-100 bacteria) for infection to occur.

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Susceptibility and resistance
• Susceptibility is general
• The disease is more severe in young children,
elderly and malnourished
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• Breast feeding is protective
Clinical manifestations

• Fever, vomiting and abdominal pain

• Generalized abdominal tenderness

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• Diarrhea are bloody& of small quantity

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• Tenesmus (strain to defecation)

• Dehydration

• Tachycardia 27
Complication  Dehydration is
Bacteremia common and
dangerous - it may

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 Rectal prolapse
cause muscular
reactive arthritis

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cramp, oliguria
 intestinal
and shock.
perforation
 death if not Rx 28
Diagnosis
• Sign and symptoms
• Stool microscopy

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• Stool culture

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Treatment
Supportive treatment
• Correct dehydration with ORS or IV fluids
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• Relieve pain and fever if necessary
Drug treatment

• First line
• Ciprofloxacin, 500 mg PO BID for 3 – 5 days. For children:7.5 –
15 mg /kg/day PO in 2 divided doses for only 3 days.

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• Alternatives

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• Sulfamethoxazole trimethoprim, 800 mg/160 mg PO BID for 5 –
7 days. For children: 6 weeks – 5 months; 100/20 mg; 6 months – 5
years, 200/40 mg; 6 – 12years, 400/80 mg BID. Or

• Ceftriaxone, 1-2g stat or 2 divided doses IM or slow IV.

For children: 20-50 mg/kg/day as a single dose or 2
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divided doses IM or slow IV.
 2.1.3. Amoebiasis
Definition

• An infection due to a protozoan parasite that

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causes intestinal or extra-intestinal disease

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• Second leading cause of mortality due parasitic
disease in humans (malaria first
Reservoir
 Human 31
Infectious agent
• Entamoeba histolytica
Trophozoite -large intestine, liver abscess, other

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extra intestinal areas and degenerate within minutes
outside the body.

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 Cyst-stools of chronic carriers
Patients Cysts-viable for weeks or months in an
appropriate moist environment.
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Susceptibility and resistance-General
Mode of transmission
• Fecal-oral transmission by ingestion of food
or water contaminated by feces containing

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the cyst.

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Period of communicability

• During the period of passing cysts of E.

histolytica, which may continue for years. 33
Life cycle of Amoebiasis
Transmission Human host
1. Cysts ingested in food, 2. Cysts excyst,
water or from hands 3.Forming trophozoites
contaminated with feces 4.Multiply in intestine
5.Trophozoites encyst

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Infective cysts passes in feces
* Trophozoites passed in feces
disintegrate

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Environment
6. Feces containing infective cysts
contaminate the environment.

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 Clinical manifestation
• Approximately 90% are asymptomatic

• Diarrhea, flatulence, and lower abdominal pain are

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the most frequent complaints.

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• Typically, stool consists watery, foul-smelling
passages that contain mucus and blood.

• Approximately 5% of all pts with symptomatic

amoebiasis present with a liver abscess. 36
Diagnosis

• Demonstration of entamoeba hystolytica cyst or

trophozoite in stool.

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• Ultrasound or CT scans can identify liver abscess &

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other extra-intestinal sites of infection

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Treatment

• First line

• Metronidazole, 500 – 750 mg PO TID for 5 – 7 days.

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For childerren: 7.5 mg/kg PO TID for 5 – 7 days

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• Alternative
• Tinidazole, 2g PO QD for 3 consecutive days. For

children: 50 – 60 mg/kg daily for 3 days

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• For eradication of cysts:
First line
• Diloxanide Furoate, Adult 500mg TID P.O.,

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for 10 days. Child over 25kg, 20mg/kg daily

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in 3 divided doses for 10 days
Alternative
• Paromycin, 25–35mg/kg/day P.O., divided
in 3 daily doses for 7 days. 39
Prevention and control
• Adequate treatment of cases

• Provision of safe drinking water

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• Proper disposal of human excreta (feces) and

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hand washing following defecation.

• Cleaning and cooking of local foods

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 2.1.4. Giardiasis
Definition
• A protozoan infection principally of the upper

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small intestine associated with symptoms of

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chronic diarrhea, steatorrhea (excess fat in the
stool), abdominal cramps, bloating, frequent
loose and pale greasy stools, fatigue and weight
loss.
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Infectious agent
• Giardia lamblia or G.duodenalis.
• It has two morphological forms,trophozoite and

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cyst.
• Trophozoite is actively motile and invading stage,

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and lives on the villi of the small intestine.
• Cyst is inactive, non-motile and non-invading
stage, and responsible for the transmission of the
disease. 42
Epidemiology
• Worldwide distribution.
• A cause of travelers' diarrhea up to 12% of travelers.
• In Ethiopia, ranges from 2.0% to 11.4%.
• Children are more affected than adults.

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• Highly prevalent in areas of poor sanitation.

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Reservoir –Humans
Mode of transmission
• Feco-oral
• Ingestion of as few as 10 cysts is sufficient to cause
infection in humans.
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Incubation period
 1 to 3 weeks; mostly after 7 to 10 days.
Period of communicability
• Entire period of infection, often months

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 Life cycle
• Both cysts and trophozoites can be found in the
feces (diagnostic stages.
• The cysts are hardy and can survive several
months in cold water. Infection occurs by the

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ingestion of cysts in contaminated water, food, or

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by the fecal-oral route (hands or fomites).
• In the small intestine, excystation releases
trophozoites (each cyst produces two
trophozoites).

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 Trophozoites multiply by longitudinal binary
fission, remaining in the lumen of the
proximal small bowel where they can be free
or attached to the mucosa by a ventral

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sucking disk .
 Encystation occurs as the parasites transit

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toward the colon.

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 TRANSMISSION
1. Cysts ingested in food,
water or from hands

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contaminated with
feces.
ENVIRONMENT
6.Feces containing

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infective cysts
HUMAN HOST
contaminate the
2.Cysts excyst, forming
environment
trophozoites
3. Multiply in intestine
4. Trophozoites encyst.
5. Infective cysts passed in feces.*
*trophozoites passed in feces
disintegrate
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Transmission and life cycle of Giardia Lamblia
Clinical manifestations
• Ranges from asymptomatic infection to severe failure
to thrive and mal-absorption.
• Young children usually have diarrhea but abdominal

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distention and bloating are frequent.

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• Adults have abdominal cramps, diarrhea, anorexia,
nausea, rarely vomiting, malaise, bloating, many
patients complain of Sulphur tasting (belching).
• Foul-smelling greasy diarrhea or fatty stools
48
(steatorrhea) without blood or mucus .
Diagnosis

• Macroscopically the stool is usually offensive,

bulky, fatty and non-bloody

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• Demonstration of Giardia lamblia cyst or

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trophozoite in feces

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Treatment

First line

• Tinidazole, single oral dose of 2g.

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• For children, 50-75mg/kg as a single dose (may be

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repeated once if necessary)

Alternative

 Metronidazole, 250-500mg P.O., TID for five days

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Prevention and control
• Good personal hygiene and hand washing before
food and following toilet use.

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• Sanitary disposal of feces.

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• Protection of public water supply from
contamination of feces.

• Case treatment

• Safe water supply 51

 2.1.5. AWD/Cholera

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What is cholera?

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52
 AWD…
Its global name is cholera
Cholera is an acute intestinal infectious diseases caused
by ingestion of food or water contaminated with the
bacterium Vibrio cholera.
 Unless treated promptly it quickly leads to severe
dehydration and death.
Cholera is -characterised by a sudden onset of profuse
painless watery diarrhoea or rice-water like
diarrhoea, often accompanied by vomiting.
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 AWD…
Standard case definition patients 5 years and
above complains s/s of dehydration like decrease
skin turgor, sunken eye ,thirsty, and irritability and
acute watery diarrheal with or with out vomiting.

Confirmed case: A suspected case in which

Vibrio cholerae O1 or O139 has been isolated
from their stool.

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 AWD…
It is locally, nationally and internationally
notifiable disease .

In Ethiopia one confirmed case of cholera is

enough to declare an outbreak.

 The case-fatality rate in untreated cases may 30-

50%, but, if treatment is applied appropriately,
should keep case-fatality rate below 1%.

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Infectious agent
Vibrio cholerae
Epidemiology
Epidemic
Pandemic
Endemic
Reservoir
Humans

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 AWD…
Mode of transmission

Ingestion of food or water directly or indirectly

contaminated with feces or vomitus of infected
person.

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 Contaminated food and/or water is the
main mode of transmission.

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Incubation period
From few hours to 5 days, usually 2-3 days.
Period of communicability

For the duration of the stool positive stage,

usually only a few days after recovery.

Antibiotics shorten the period of communicability

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Susceptibility and resistance

Varies.

Gastric achlorhydria increases risk of illness.

Breast-fed infants are protected.

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Risk factors for Cholera
 Overcrowding (internally displaced people, refugee,
camps, population gatherings, etc.)

 Inadequate quantity and/or quality of water

 Inadequate personal hygiene

 Poor washing facilities

 Inappropriate or poor sanitation

 Inadequate food safety

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Clinical manifestations
Abrupt painless watery diarrhea; the diarrhea looks
like rice water and nausea , vomiting.
In severe cases, several liters of liquid may be lost in
few hours leading to shock.
Severely ill patients have sunken eyes and cheeks,
scaphoid abdomen, poor skin turgor, and thready or
absent pulse.
But usually no fever.

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 c/ m…….

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 AWD…
Diagnosis

Based on clinical grounds.

Stool microscope

Culture (stool) confirmation.

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 AWD…
Treatment
For dehydration in mild case- ORS.
For severe cases- Ringer lactate i.v. drips
(alternatively Normal Saline) should be given 50 -
100 ml/min until shock is reversed
Drug therapy:
Doxycycline, 100 mg bid, p.o. for 3 days. For
children: 6mg/kg daily for 3 days.
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Alternatives

Tetracycline 500mg p.o. q.i.d for 3-5 days.

Sulfamethoxazole+trimethoprim, 800 mg/160

mg P.O. BID for 5 days. For children 6 weeks – 5
months: 100/20 mg; 6 months – 5 yrs: 200/40 mg;
6 – 12 yrs: 400/80 mg BID for 5 days.

Ciprofloxacin, 500 mg PO BID, for 3-5 days

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 Rx………..

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 AWD…
Prevention and control
 Case treatment

 Safe disposal of human excreta and control of

flies

 Safe public water supply

 Hand washing and sanitary handling of food

 Control and management of contact cases

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 Tips

 Cholera is rarely fatal if the lost fluids

and electrolytes are adequately
replaced.
 The mortality rate with proper treatment
is less than 1% and most patients
recover within 3 to 7 days.
 In untreated cases, the case fatality rate
is greater than 50%. Death may occur
within a few hours if the diarrhea is
severe.

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