CDC Med surg I module Part I.pdf

 Introduction to CDC
 Air-borne diseases
 Fecal oral diseases
 Food intoxications
 References
 Hawker, Jeremy, etal. Communicable disease control and health
protection handbook . 4th edition. | Hoboken, N.J. :Wiley-
Blackwell, 2019
 Roger Webber. Communicable Diseases, A Global Perspective. 5th
Edition. 20th Anniversary Edition, 2016
 Food, Medicine and Healthcare Administration and Control,
Standard treatment guidelines for health centers, 2014
2

 Define communicable diseases
 Define common epidemiological terms
 Discuss the chain of communicable disease transmission
 Identify types of carriers
 Explain the natural history of a disease
 Discuss the three level of disease prevention
4

 are illnesses due to specific infectious agents or its
toxic products
 arise through transmission of that agent, or its toxic
products from an infected person, animal or
inanimate reservoir to a susceptible host,
 transmission is either direct or indirect, through an
intermediate plant or animal host, vector or
inanimate environment
5

 Two major dimensions
 Time course
 Acute – rapid onset and short duration
 Chronic – prolonged duration
 Cause
 Infectious
 Non-infectious
6

 Communicable diseases in Africa
 Many of them are very common
 ƒ
Some of them are serious and cause death and disability
 ƒ
Some of them cause widespread out breaks of disease or
epidemics
 ƒ
Most of them are preventable by fairly simple means.
 ƒ
Poor socio-economic status of the individuals makes them
vulnerable to a variety of diseases
 ƒ
Low educational status
 ƒ
Lack of access to modern health care service
7

 Epidemiology- the study of the frequency,
distribution and determinants of disease and
other health related conditions in human
populations, and the application of this study
to the promotion of health and to the
prevention and control of health problems.
9

 Epidemic - the occurrence of any health related
condition in a given population in excess of the usual
frequency in that population.
 Endemic - a disease that is usually present in a
population or in an area at a more or less stable level.
 Sporadic - a disease that does not occur in that
population, except at occasional and irregular intervals.
 Pandemic - an epidemic disease which occurs worldwide
10

 Disease - a state of physiological or psychological
dysfunction.
 Infection - the entry and development or multiplication of
an infectious agent in the body
 Contamination – presence of a living infectious agent upon on a
body surface, in clothes, bedding, toys, surgical instruments or
dressings, or other inanimate articles
 Infestation – the lodgment, development and reproduction of
arthropods on the surface of the body/ invasion of the gut by
parasitic worms
11

 Infectious diseases - caused by microbes and can be
transmitted to other persons.
 Infectious agent- an agent capable of causing infection
12

 Refers to the logical sequence of factors or
links of a chain that are essential to the
development of the infectious agent
and propagation of disease.
 There are six factors involved in the chain of
disease transmission
13

 These factors are:
 Infectious agent (etiology or causative agent)
 Reservoir
 Portal of exit
 Mode of transmission
 Portal of entry
 Susceptible host
14

 Infectious agent: An organism that is capable of
producing infection or infectious disease.
 Reservoir of infection:
 any person, animal, arthropod, plant, soil or substance (or
combination of these)
 where an infectious agent normally lives and multiplies,
 on which it depends primarily for survival and,
 where it reproduces itself in such a manner that it can be
transmitted to a susceptible host.
15

 Types of Reservoirs
 Human
▪ e.g. measles, smallpox, typhoid, meningococcal
meningitis, gonorrhea and syphilis.
▪ The cycle of transmission is from human to human
 Animals - zoonotic diseases
▪ e.g. bovineTB, brucellosis, anthrax, rabies
 Non – living things
▪ e.g. botulism, tetanus, gas gangrene
16

 Portal of exit (mode of escape from the
reservoir):
 This is the site through which the agent escapes
from the reservoir. ƒ
 GIT: typhoid fever, bacillary dysentery, amoebic
dysentery, cholera, ascariasis, etc.
 Respiratory: tuberculosis, common cold, etc.
 Skin and mucus membranes: Syphilis
17

 Mode of transmission (mechanism of
transmission of infection):
 Refers to the mechanisms by which an infectious
agent is transferred from one person to another or
from a reservoir to a new host.
 Transmission may be direct or indirect.
18

 Direct transmission: Consists of essentially immediate
transfer of infectious agents from an infected host or
reservoir to an appropriate portal of entry.
▪ Direct vertical – e.g. trans placental transmission of HIV
▪ Direct horizontal – Direct touching, biting, kissing, sexual
intercourse, droplet spread onto the conjunctiva or onto
mucus membrane of eye, nose or mouth during sneezing
coughing, spitting or talking
19

 Indirect transmission
▪ Vehicle-borne transmission: Indirect contact through
contaminated inanimate objects (fomites) like:
▪ ƒ
Bedding, toys, handkerchiefs, soiled clothes,
▪ Cooking or eating utensils, surgical instruments.
▪ ƒ
Contaminated food and water
▪ ƒ
Biological products like blood, serum, plasma or IV-fluids
20

▪ Vector-borne transmission: Occurs when the infectious
agent is conveyed by an arthropod (insect) to a susceptible
host.Two types:
▪ Mechanical transmission
▪ Biological transmission
21

▪ Air-borne transmission:
▪ Dissemination of microbial agent by air to a suitable portal
of entry, usually the respiratory tract.
▪ Two types of particles are implicated in this kind of spread:
Dust and Droplet nuclei
22

 Portal of entry:The site in which the
infectious agent enters to the susceptible
host. For example:
 ƒ
Mucus membrane
 ƒ
Skin
 ƒ
Respiratory tract
 GIT
 Blood
23

 Susceptible host (host factors):
 A person lacking sufficient resistance to a particular
pathogenic agent to prevent disease if or when
exposed.
 Occurrence of infection and its outcome are in part
determined by host factors.
 The term “immunity” is used to describe the ability of
the host to resist infection.
24

 Carrier - is an infected person or animal who
does not have apparent clinical disease but is
a potential source of infection to others.
 Healthy or asymptomatic carriers
 Incubatory or precocious carriers
 Convalescent Carriers
 Chronic Carriers
25

 Healthy or asymptomatic carriers – individuals whose
infection remains unapparent.
 Incubatory or precocious carriers: These are individuals
or persons who excrete the pathogen during the
incubation period.
 Convalescent Carriers:These are those who continue to
harbor the infective agent after recovering from the
illness. E.g. Diphtheria, Hepatitis B virus
 Chronic Carriers:The carrier state persists for a long
period of time. E.g.Typhoid fever, Hepatitis B virus
infection
26

 Refers to the progress of a disease process in
an individual over time, in the absence of
intervention.
 The process begins with exposure to or
accumulation of factors capable of causing a
disease.
27

 There are four stages in the natural history of
a disease.These are:
 Stage of susceptibility
 Stage of pre-symptomatic (sub-clinical) disease
 Stage of clinical disease
 Stage of disability or death
28

 Stage of susceptibility - In this stage, disease
has not yet developed, but the groundwork
has been laid by the presence of factors that
favor its occurrence.
 Example: unvaccinated child is susceptible to
measles.
29

 Stage of Pre-symptomatic (sub-clinical)
disease
 In this stage there are no manifestations of the
disease but pathologic changes (damages) have
started to occur in the body.
 The disease can only be detected through special
tests since the signs and symptoms of the disease
are not present.
30

 The Clinical stage
 At this stage the person has developed signs and
symptoms of the disease.
 The clinical stage of different diseases differs in
duration, severity and outcome.
 The outcomes of this stage may be recovery,
disability or death.
31

 Stage of recovery, disability or death
 Some diseases run their course and then resolve
completely either spontaneously or by treatment.
 In others the disease may result in a residual
defect, leaving the person disabled for a short or
longer duration.
 Other diseases will end in death.
32

 Incubation period: It is the interval of time between
infection of the host and the first appearance of
symptoms and signs of the disease.
 Prodromal period: It is the interval between the
onset of symptoms of an infectious disease and the
appearance of characteristic manifestations.
 Period of communicability:The period during
which that particular infectious agent is transmitted
from the infected person to the susceptible host.
34

“An ounce of prevention is worth a
pound of cure.”
Benjamin Franklin
35

 Primary prevention:The objectives here are
to promote health, prevent exposure, and
prevent disease.
 Health promotion
 Prevention of exposure
 Prevention of disease
36

 Secondary prevention
 Preventive activities after the biological onset of
disease, but before permanent damage sets in
 The objective here is to stop or slow the progression
of disease so as to prevent or limit permanent
damage, through the early detection and treatment
of disease.
37

 Tertiary prevention:
 After permanent damage has set in, the objective of
tertiary prevention is to limit the impact of that damage.
 The impact can be physical, psychological, social (social
stigma or avoidance by others), and financial.
 Rehabilitation refers to the retraining of remaining
functions for maximum effectiveness, and should be seen
in a very broad sense, not simply limited to the physical
aspect.
38

 There are three main methods of controlling
communicable diseases:
 Elimination of the Reservoir
 Interruption of transmission
 Protection of susceptible host
39

 Elimination of the Reservoir
 Human Reservoir
▪ Detection and adequate treatment of cases
▪ Isolation - separation of infected persons for a
period of communicability of the disease
▪ Quarantine - limitation of the movement of
apparently well person who has been exposed
to the infectious disease for a duration of the
maximum incubation period of the disease
40

 Animal Reservoir
▪ Plague: Rats are regarded as a pest and the
objective would be to destroy the rat and
exclude it from human habitation.
▪ ƒ
Rabies: Pet dogs can be protected by
vaccination but stray dogs are destroyed.
▪ ƒ
Infected animals used for food are examined
and destroyed.
41

 Non-living Reservoir
▪ Possible to limit exposure to the affected area
(e.g. soil, water, forest, etc.).
42

 Interruption of transmission
 Improvement of environmental sanitation and
personal hygiene
 Control of vectors
 Disinfection and sterilization
43

 Protection of the susceptible host
 Immunization: Active or Passive
 ƒ
Chemoprophylaxis- (e.g. Malaria, meningococcal
meningitis, etc.)
 ƒ
Lifestyle and nutritional adjustment
 ƒ
Personal protection. (e.g. wearing of shoes, use of
mosquito bed net, insect repellents, etc.)
44

 List common air-borne diseases.
 Identify the common modes of air-borne diseases
transmission.
 Discuss the diagnosis and treatment of common
airborne diseases.
 Apply preventive and control methods for air-borne
diseases
46

 organisms causing the diseases in the air-borne
group enter the body via the respiratory tract.
 when a patient or carrier of pathogens talks,
coughs, laughs, or sneezes, he/she discharges fluid
droplets
 smallest of these remain up in the air for some time
and may be inhaled by a new host.
47

 Droplets with a size of 1-5 microns are quite easily
drawn in to the lungs and retained there
 Droplets that are bigger in size will not remain air-
borne for long but will fall to the ground and mix
with dust
 Air-borne diseases, obviously, will spread more
easily when there is overcrowding
48

 An acute highly communicable viral disease
 Infectious agent - Measles virus (paramyxovirus
family)
 Epidemiology
 Highly contagious disease which has been a cause of
millions of deaths
 More than 140, 000 people died from measles in 2018
 In Ethiopia, there were 66,719 (70.9%) confirmed cases,
out of the 94,104 suspected measles cases reported from
January 2006 to December 2016 (Desta et al 2018).
49

 Epidemiology
 Prior to widespread immunization, measles was
common in childhood so that more than 90% of
people had been infected by age 20
 few went through life without any attack
 Reservoir- Humans
50

 Mode of transmission
 Airborne by droplet spread,
 direct contact with nasal or throat secretions of
infected persons and
 by articles freshly solid with nose and throat
secretion (less commonly)
 Greater than 94% herd immunity may be needed
to interrupt community transmission
51

 Incubation period - 7-18 days from exposure
to onset of fever.
 Period of communicability- slightly before the
prodromal period to four days after the
appearance of the rash and minimal after the
second day of rash
52

 Susceptibility and resistance
 All those who are non-vaccinated or have not had
the disease
 Permanent immunity is acquired after natural
infection or immunization
53

 Clinical Manifestations
 Prodromal fever, conjunctivitis, coryza, cough
 Koplik spots on the buccal mucosa
 A characteristic red blotchy rash appears on the 3rd-7th day,
beginning on the face, gradually becoming generalized, lasting
4-7 days.
 Leukopenia
54

 Complications
 Pneumonia
 Bacterial superinfection
 Acute thrombocytopenic purpura
 Encephalitis
 Transient hepatitis
 Subacute sclerosing panencephalitis
57

 Diagnosis
 Clinical evaluation
 Serologic testing
 Viral detection via culture or reverse transcription–polymerase
chain reaction (RT-PCR)
 Treatment
 Supportive care
 For children, vitamin A
 Standard and airborne precautions
58

 Nursing care
 Advise patient to have bed rest.
 Relief of fever.
 Provision of non-irritant small frequent diet.
 Shorten the fingernails.
 Prevention
 Educate the public about measles immunization
 Immunization of all children (less than 5 years of age) who had
contact with infected children.
 Provision of measles vaccine at nine months of age.
 Initiate measles vaccination at 6 months of age during epidemic and
repeat at 9 months of age.
59

 Definition - An acute viral disease of the respiratory
tract
 Infectious agent - Influenza viruses (Types A,B and C)
 Epidemiology
 Influenza occurs all over the world, with an annual global
attack rate estimated at 5-10% in adults and 20-30% in
children.
 In temperate climates outbreaks are experienced mainly
during the winter season, influenza occurs more unpredictably
in tropical regions.
61

 Reservoir
 Mainly Humans for all types.
 Humans are the only known reservoir of influenza
type C.
 Influenza B generally infects humans, but at least two
reports have documented influenza B in seals.
 Influenza A viruses may infect both humans and
some animals.
62

 Influenza is primarily transmitted from person to person via
large, virus-laden droplets (more than 5 microns in diameter)
that are generated when infected persons cough or sneeze.
 These large droplets can then settle on the mucosal surfaces of
the upper respiratory tracts of susceptible persons who are
within six feet of infected persons.
63

 Incubation period 2 days (range, 1–4 days)
 Period of communicability - 3-5 days from clinical onset
in adults; up to 7 days in young children.
 When a new sub-type appears,
 All children and adults are equally susceptible.
 Infection produces immunity to the specific infecting agent
64

 Clinical Features
 Onset of influenza symptoms is sudden.
 Respiratory symptoms include cough, sore throat, and runny
or stuffy nose.
 Systemic symptoms generally include fever, chills, headache,
malaise, and myalgia.
 Vomiting and diarrhea may also occur, especially in children.
 Recovery is rapid; fever usually resolves within 3 to 4 days and
other symptoms within approximately 7 days.
65

 Diagnosis
 Clinical evaluation
 RT-PCR tests
 Pulse oximetry and chest x-ray for patients
 Treatment
 Same as common cold
 ƒ
Anti-pain and antipyretic
 ƒ
High fluid intake
 ƒ
Bed rest
 ƒ
Balanced diet intake
66

 Prevention and control
 Educate the public in basic personal hygiene,
especially the danger of unprotected coughs and
sneezes and hand to mucus membrane transmission.
 Vaccination
▪ Influenza vaccination is recommended annually for persons
age 6 months and above
▪ Particularly important for persons at increased risk for
severe illness and complications from influenza
67

 Definition
 An acute bacterial disease involving primarily tonsils,
pharynx, nose, occasionally other mucus membranes
or skin and sometimes the conjunctiva or genitalia.
 Infectious agent
 Corynebacterium diphtheriae
▪ Toxin-producing strains
▪ Non-toxin-producing strains
68

 Epidemiology
 Diphtheria occurs worldwide, particularly in countries
with suboptimal vaccination coverage.
 Diphtheria is rare in industrialized countries.
 Because it is a rare disease, seasonal and geographic
distribution patterns are no longer observed.
 Reservoir - Human
69

 Most often person-to-person through respiratory
droplets.
 Transmission may also occur from exposure to
infected skin lesions or articles soiled with discharges
from these lesions.
 Incubation period - usually 2-5 days
70

 Period of communicability
 variable, until virulent bacilli have disappeared from
discharges and lesion
 usually 2 weeks or less
 Susceptibility is universal.
 Infants borne to immune mothers are relatively
immune, but protection is passive and usually lost
before 6 months.
71

 Clinical manifestations
 Pharyngeal andTonsillar Diphtheria
▪ Onset of pharyngitis is gradual
▪ Early symptoms include malaise, sore throat, anorexia, and
low-grade fever (less than 38°c)
▪ Within 2 to 3 days, a bluish-white membrane forms and
extends, varying in size from covering a small patch on the
tonsils to covering most of the soft palate.
▪ While some patients may recover at this point without
treatment, others may develop severe disease.
72

 Pharyngeal andTonsillar Diphtheria
▪ Patients with severe disease may develop marked edema of
the submandibular areas and the anterior neck along with
lymphadenopathy, giving a characteristic “bull neck”
appearance.
73

 Laryngeal Diphtheria
▪ can be either an extension of the pharyngeal form or can
involve only this site.
▪ symptoms include fever, hoarseness, and a barking cough.
▪ the membrane can lead to airway obstruction, coma, and
death.
75

 Anterior Nasal Diphtheria
▪ The onset of anterior nasal diphtheria looks much like the
common cold
▪ A white membrane usually forms on the nasal septum.
▪ The disease is usually fairly mild because of apparent poor
systemic absorption of toxin from this location.
76

 Cutaneous Diphtheria
▪ scaling rash or by ulcers with clearly demarcated edges and
an overlying membrane
▪ quite common in the tropics
▪ systemic complications occurs less frequently with
cutaneous compared to other forms of diphtheria.
77

 Diagnosis
 Based on clinical and epidemiological grounds
 ƒ
Bacteriologic examination of discharges from lesions
 Treatment
 Diphtheria antitoxin
 Erythromycin
 Procaine penicillin G
79

 Educate the public about the importance of
immunization
 Diphtheria toxoid immunization
 Concurrent and terminal disinfection of articles in
contact with patient and soiled by discharges of
patient
 Single dose of penicillin (IM) or 7-10 days course of
Erythromycin (PO) is recommended for all persons
exposed to diphtheria
80

 Definition - An acute bacterial disease involving the
respiratory tract
 Infectious agent - Bordetella pertussis
 Epidemiology
 Pertussis remains a major health problem among children
worldwide.
 More than 24 million new pertussis cases occurred globally
among children younger than age 5 years in 2014 and caused
an estimated 160,700 deaths.
81

 Reservoir – Human
 person-to-person, through contact with respiratory droplets
 by contact with airborne droplets of respiratory secretions
 by contact with an infected person’s freshly contaminated
articles (less frequently)
 Incubation period - is commonly 7 through 10 days, with
a range of 4 through 21 days
82

 from the beginning of the catarrhal stage through the
third week after the onset of paroxysms or,
 until 5 days after the start of effective antimicrobial
treatment
 Susceptibility to non immunized individuals is
universal.
 One attack usually confers prolonged immunity but
may not be lifelong
83

 Clinical features
 Catarrhal stage
▪ lasts about 1-2 weeks
▪ insidious onset of coryza, sneezing, low-grade fever,
and a mild, occasional cough
▪ cough gradually becomes more severe
84

 Paroxysmal stage
▪ usually lasts 1 to 6 weeks but may persist for up to 10 weeks
▪ the diagnosis of pertussis is usually suspected
▪ bursts, or paroxysms, of numerous, rapid coughs
▪ at the end of the paroxysm, a long inspiratory effort is
usually accompanied by a characteristic high-pitched whoop
85

 Paroxysmal stage
▪ attacks generally occur more frequently at night, with an
average of 15 attacks per 24 hours
▪ the attacks might increase in frequency, remain at the same
level for 2 to 3 weeks, and then gradually decrease
86

 Convalescent stage
▪ recovery is gradual
▪ the cough becomes less paroxysmal and disappears in 2
to 3 weeks
▪ paroxysms often recur with subsequent respiratory
infections for many months after the onset of pertussis
87

 Diagnosis
 History and physical examination at phase two
 Nasopharyngeal cultures, direct fluorescent
antibody testing, and polymerase chain
reaction (PCR) testing
 Serologic testing
88

 Treatment
 First line
▪ Erythromycin, 12.5mg/kg P.O. QID for ten days
 Alternatives
▪ Clarithromycin, 15 – 20 mg/kg/24hr P.O., divided in to two
doses for 7 days or,
▪ Azithromycin, 10mg/kg/24hr, P.O. for 5 days
89

 Nursing care
 Proper feeding of the child.
 Encourage breastfeeding immediately after an attack
(each paroxysm).
 Proper ventilation- continuous well humidified
oxygen administration.
 Reassurance of the mother (care giver)
90

 Active immunization against pertussis is part of
standard childhood vaccination
 Prophylaxis for high risk groups
▪ A 7- to 14-day course of oral erythromycin 500 mg 4 times a
day or 10 to 12.5 mg/kg 4 times a day.
91

 Definition - A chronic and infectious mycobacterial
disease important as a major cause of illness and death
in many parts of the world
 Mycobacterium tuberculosis- human tubercle bacilli
(commonest cause)
 Mycobacterium bovis- cattle and man infection
 Others - M. africanum, and M. microti
92

 Epidemiology
 TB is present in all countries and age groups.
 Worldwide,TB is the 13th leading cause of death and the
second leading infectious killer.
 In 2020, an estimated 10 million people fell ill withTB
worldwide
 Multidrug-resistantTB (MDR-TB) remains a public health crisis
and a health security threat.
 The estimated incidence rate forTB was 140 per 100,000
population and the mortality rate was 21 per 100,000
population
93

 Almost exclusively from inhalation of airborne
particles (droplet nuclei) containing M. tuberculosis.
 ExtrapulmonaryTB, other than laryngeal infection, is
generally not communicable.
▪ Urine is infectious in cases of renalTB.
 BovineTB results mainly from ingestion of
unpasteurized milk and dairy products.
94

 Incubation period
 The period from infection to development of the
primary lesion or significant tuberculin reaction is
about 3–9 weeks.
 as long as viable bacilli are being discharged from the
sputum
 risk of transmission is significantly reduced within
days to 2 weeks after commencing appropriate
chemotherapy
95

 those in close contact with a case of activeTB
 immunosuppressed patients, including those with HIV
infection (any CD4 count), the elderly and diabetics; and
infants aged less than 5 years
 drug- and alcohol-dependent people
 people living in substandard, overcrowded conditions or those
who are homeless
 institutionalized people, including prisoners
 health professionals
96

 Phases of disease progress
 Primary infection
 Latent infection
 Active infection
97

 Clinical Manifestations (PTB)
 a chronic cough, sometimes accompanied by
hemoptysis (usually more than two weeks)
 fevers and night sweats
 loss of weight
 malaise and fatigue.
98

 Clinical Manifestations (EPTB)
 TB lymph adenitis
▪ ƒ
Slowly developing and painless enlargement of lymph nodes
followed by matting and drainage of pus.
 Tuberculosis pleurisy
▪ ƒ
Pain while breathing in, dull lower chest pain, slight cough,
breathlessness on exertion.
 TB of bones and joints
▪ ƒ
Localized pain and/or swelling, discharging of pus, muscle
weakness, paralysis and stiffness of joints.
99

 Clinical Manifestations (EPTB)
 IntestinalTB
▪ ƒ
Loss of weight and appetite
▪ Abdominal pain, diarrhea and constipation
▪ ƒ
Mass in the abdomen
▪ ƒ
Fluid in the abdominal cavity (ascites)
 Tuberculosis meningitis
▪ ƒ
Headache, fever, vomiting, neck stiffness
▪ Mental confusion of insidious onset
100

 Diagnosis (PTB)
 Chest x-ray
 Acid-fast stain and culture
 Tuberculin skin test (TST) or interferon-gamma release assay
(IGRA)
 When available, nucleic acid–based testing (Xpert MTB)
101

 Diagnosis (EPTB)
 CSF analysis
 Bone marrow stain ,blood culture-milliary
 Liver biopsy
 Urine-AFB on culture
 Pericardial fluid analysis
 U/S-abdomen,pelvic/ovary/kidney for complications
102

 Treatment
 The treatment strategy is referred to as DOT
 The following drugs are being used for treatment of
TB in Ethiopia.
▪ Rifampin (R)
▪ Isoniazid (H)
▪ ƒ
Pyrazinamide (Z)
▪ ƒ
Ethambutol(E)
▪ Streptomycin (S)
 There are four categories of treatment
103

 Treatment
 Category I
▪ new patients who have smear-positive Pulmonary
TB
▪ seriously ill patients with smear-negative
Pulmonary and Extra-pulmonaryTB
▪ ƒ
2 (RHZE) / 6 (EH) or 2 (RHZE) / 4RH
104

 Treatment
 Category II
▪ who relapsed after being treated and declared free from the
disease
▪ those patients who are previously treated for more than one
month with short or long term therapy, and found to be
smear positive upon return
▪ who still remain smear positive while under treatment ,at
month five and beyond
▪ The treatment regimen for this category is:
2S (RHZE) / 1 (RHZE) / 5E3(RH)3
105

 Treatment
 Category III
▪ new cases of smear negative PulmonaryTB,
▪ new cases of less severe Extra-pulmonaryTB and
▪ TB in Children
▪ The Short course chemotherapy regimen is:
[2(RHZE/)/6(EH)]
▪ The long course regimen is: 2 S (EH) / 10 (EH)
106

 Treatment
 Category IV
▪ Treatment of chronic cases
▪ These patients are considered essentially incurable
with first line drugs.
▪ still smear +ve after supervised retreatment
▪ Treated using 2nd line drugs
107

 Treatment
 Drug resistantTB
▪ Mono-resistance: Resistance to one anti-tuberculosis drug.
▪ Poly-resistance: Resistance to more than one anti-
tuberculosis drug, but not to Isoniazid and Rifampicin.
▪ Multidrug-resistance (MDR)-TB: Resistance to at least
isoniazid and rifampicin.
108

 Treatment
 Drug resistantTB
▪ Extensive drug-resistance (XDR-TB): Resistance to any of
the fluoroquinolones, and at least one of the three injectable
Second Line Drugs (capreomycin, kanamycin and Amikacin),
in addition to resistance to INH and rifampicin
▪ Total drug-resistance (TDR-TB): resistance to all antiTB
drugs.
109

 Treatment
 MDRTB
▪ are treated with standardized second line treatment
regimen for at least 18-24 months
▪ Standard treatment regimen in Ethiopia is:
8E-Z-Km (Am)-Lfx-Eto-Cs/12 E-Z-Lfx–Eto–Cs
▪ Kanamycin (Km), Amikacin (Am), Capreomycin (Cm),
Levofloxacin (Lfx), Moxifloxacin (Mfx), Ethionamide (Eto),
Cycloserine (Cs)
110

 Nursing care
 Educate the patient how and when to take the prescribed
medication.
 Tell the patient not to stop the medication unless he/she is told
to do so.
 Tell the patient to come to the health institution if he/she
develops drug side effects.
 Advice the patient on the importance of taking adequate and
balanced diet and to eat what is available at home
111

 Prevention
 Chemoprophylaxis for contacts (INH/IPT)
▪ individuals with latent infection with Mycobacterium
tuberculosis in order to prevent progression to active
disease.
▪ to all HIV-infected individuals who are unlikely to have active
TB
▪ for under-five asymptomatic children who are exposed toTB
within the past one year.
112

 Prevention
 Immunization of infants with BCG
 Educate patients withTB about the mode of disease
transmission
 General measures
▪ ƒ
Adequate nutrition
▪ ƒ
Health housing
▪ ƒ
Environmental sanitation
▪ ƒ
Personal hygiene
▪ ƒ
Active case finding and treatment
113

 Definition
 A chronic bacterial disease of the skin, peripheral nerves and,
in lepromatous patients, the upper airway
 Mycobacterium leprae
 Epidemiology
 The overwhelming majority of cases are found in developing
countries.
 In general leprosy is more common among males with a ratio
of approximately 1.5 to 1.
 Ethiopia is one of the 22 Leprosy high burden countries
114

 Reservoir – Human
 The means of transmission is not fully understood.
 The disease is probably spread by the respiratory
route;
 nasal discharge from untreated patients with
lepromatous (multibacillary) disease frequently
contains large numbers of bacilli.
 Occasionally the organisms may enter through
broken skin
115

 Incubation period - 9 months to 20 years
 Infectiousness is lost in most instances within 3
months of continuous and regular treatment
 Everyone is susceptible to infection;
 Children aged between 5 and 9 years are at greatest
risk.
116

 Classification
 Paucibacillary (PB): ≤ 5 skin lesions with no bacteria detected
on samples from those areas
 Multibacillary (MB): ≥ 6 skin lesions, bacteria detected on
samples from skin lesions, or both
 Leprosy can also be classified by cellular response and
clinical findings:
 Tuberculoid
 Lepromatous
 Borderline
117

 Classification
 Tuberculoid
▪ Non-pruritic skin lesions consist of one or a few
hypoesthetic, centrally hypopigmented macules with sharp,
raised borders
▪ Areas affected by this rash are numb because of damage to
the underlying peripheral nerves
118

 Classification
 Lepromatous
▪ many areas of the body, including the kidneys, nose, and
testes, may be affected
▪ skin macules, papules, nodules, or plaques, which are often
symmetric
▪ peripheral neuropathy is more severe than tuberculoid
leprosy
119

 Classification
 Borderline
▪ Features of both tuberculoid and lepromatous leprosy are
present.
▪ Without treatment, borderline leprosy may become less
severe and more like the tuberculoid form, or it may worsen
and become more like the lepromatous form
120

 Complications
 peripheral neuropathy, which causes deterioration of
the sense of touch and a corresponding inability to
feel pain and temperature.
 Muscle weakness can result in deformities
 Papules and nodules can be particularly disfiguring on
the face.
122

 Complications
 Feet: Plantar ulcers with secondary infection are a major cause
of morbidity, making walking painful.
 Nose: Damage to the nasal mucosa can result in chronic nasal
congestion and nosebleeds and, if untreated, erosion and
collapse of the nasal septum.
 Eyes: Iritis may lead to glaucoma, and corneal insensitivity
may lead to scarring and blindness.
 Sexual function: erectile dysfunction and infertility.
 Kidneys: Amyloidosis and consequent renal failure occasionally
occur in lepromatous leprosy.
123

 Diagnosis
 Complete skin examination
 Skin lesion are tested for sensation (light touch, pink
prick, temperature discrimination)
 Demonstration ofAFB in skin smears made by scraped incision
method.
 ƒ
Skin biopsy confined to the affected area should be sent to the
experienced pathologists in leprosy diagnosis
125

 Treatment – Multi drug treatment (MDT)
 Rifampicin (R): are supplied as 150mg and 300mg
tablets to be administered once a month.
 Clofazemine (C): are supplied as 50mg and 100mg
tablets to be administered orally.
 Dapsone( DDS):is supplied as 50mg and 100mg tables
to be administered daily.
127

 Treatment
 PB MDT
▪ This regimen consists of Rifampicin and Dapsone for a total
duration of 6 months.
▪ It is to be prescribed to all cases classified as Paucibacillary
(PB) Leprosy
▪ Monthly supervised dose is Rifampicin & Dapsone, the daily
self-administered dose is Dapsone and is taken every day
128

 Treatment
 MB MDT
▪ This regimen consists of Rifampicin, Dapsone and
Clofazimine to be taken for 12 months.
▪ It is to be prescribed to all cases classified as Multibacillary
(MB) Leprosy
▪ The monthly, supervised dose is with Rifampicin,
Clofazemine & Dapsone,The daily, self-administered dose is
with Clofazemine and Dapsone and is taken every day for 12
months 129

 Treatment
 Prevention
▪ Because leprosy is not very contagious, risk of spread is low.
▪ Only the untreated lepromatous form is contagious, but
even then, the infection is not easily spread.
▪ Household contacts (particularly children) of patients with
leprosy should be monitored for development of symptoms
and signs of leprosy. Once treatment has begun, leprosy
cannot be spread.
▪ The best prevention is avoiding contact with bodily fluids
from and the rash on infected people
130

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