communicable diseases.pdf

introduction
• Caused by bacteria Corynebacterium diptheriae
• The bacteria multiply locally usually in the throat, and elaborate a
powerful exotoxin which is responsible for:
Formation of a greyish or yellowish membrane commonly over the
tonsils, pharynx or larynx

introduction
Marked congestion, oedema or local tissue destruction.
Enlargement of the regional lymph nodes
Signs and symptoms of toxemia

Agent factors
AGENT: Corynebacterium diptheriae
SOURCE OF INFECTION: Case or Carrier
NOTE:
carrier are important as source of infection: 95% of total disease
transmission.

Agent factors
Infective material:
Nasopharyngeal secretions, discharges from skin lesions, contaminated
fomites.
Period of infectivity:
14-28 days from onset of disease; longer for carriers

Host factors
AGE: particularly affects children aged 1-5 years
SEX: both sexes are affected.

Mode of transmission
• Mainly by droplet infection.
• Can also be transmitted by cutaneous lesions and fomites

Incubation period
• 2-6 days

Clinical features
• Sore throat
• Difficulty in swallowing
• Low grade fever
• Examination of throat may show
presence of pseudomembrane
• bull necked” appearance.

Clinical features
Laryngotracheal diphtheria
• Fever
• Hoarseness and croupy cough
• dyspnea

Clinical features
Cutaneous diphtheria
Secondary infection to previous skin abrasion or infection
The presenting lesion, often an ulcer, may be surrounded by erythema
and covered with a membrane.

control
• Isolation
• vaccination

intr0duction
• Acute infectious disease, usually of young children, caused by B.
pertussis.
• Also known as hundred day cough

Agent factors
Agent : Bordetella pertussis (5% cases by B. parapertussis)
Source of infection: Case
Infective material: bacilli occurs abundantly in the nasopharyngeal and
bronchial secretions. Objects freshly contaminated by such discharges
are also infective.
Secondary attack rate: 90% in unimmunized household contacts.

Host factors
Age: primarily disease of infant and pre school children
Sex: incidence and fatality are observed to be more among children.

Environmental factors
• More cases occurring during spring and winter.
• Risk of exposure is greater in the lower social classes living in
overcrowded conditions.

Droplet infection and direct contact.

Clinical features
Catarrhal stage:
lasting for about 10 days. It is characterized by its insidious onset,
lacrimation, sneezing and coryza, anorexia and malaise, and a hacking
night cough that becomes diurnal.

Clinical features
❑ Paroxysmal stage:
▪ lasting for 2-4 weeks.
▪ It is characterized by bursts of rapid, consecutive coughs followed by a
deep, high-pitched inspiration (whoop). It is usually followed by
vomiting.
▪ In young infants it may cause cyanosis and apnoea.
▪ In adults and adolescents, uncharacteristic, persistent cough may be
the only manifestation of the disease.

Clinical features
❑ Convalescent stage:
stage, lasting for 1-2 weeks. The illness generally lasts 6 to 8 weeks.

control
✓Early diagnosis, isolation and treatment of cases.
❖Drug of choice: erythromycin
✓Active immunization : DPT vaccine.

introduction
Acute respiratory infections (ARI) may cause inflammation of the
respiratory tract anywhere from nose to alveoli, with a wide range of
combination of symptoms and signs.
Classified by clinical syndromes depending on the site of infection and
is referred to as ARI of upper (AURI) or lower (ALRI) respiratory tract.

introduction
The upper respiratory tract infections include common cold, pharyngitis
and otitis media.
The lower respiratory tract infections include epiglottitis, laryngitis,
laryngotracheitis, bronchitis, bronchiolitis and pneumonia.

introduction
The clinical features include running nose, cough, sore throat, difficult
breathing and ear problem.
Fever is also common in acute respiratory infections. Most children with
these infections have only mild infection, such as cold or cough.
However, some children may have pneumonia which is a major cause of
death.

Agent factors
Numerous and include bacteria and viruses

Host factors
▪ Case fatality rate are higher in young infants.
▪ Age-specific mortality rates show wide differences between countries.
▪ In general, rates tend to be high in infants and young children, and in
the elderly in all countries.

• Transmitted by airborne route

CB-IMNCI classification
• Red: Severe Pneumonia or Very Severe Disease
• Yellow: Pneumonia
• Green: Cough and Cold

management
PNEUMONIA
• Classified as pneumonia if he/she has cough and/or difficult breathing
plus at least one of the following signs:
• Fast breathing: Age 2-12 months, > 50/min Age 1-5 years,> 40/min
Lower chest wall indrawing On auscultation, crackles may be present.
• Treatment Treat child as outpatient. Advise to continue feeding. Treat
wheeze with oral Salbutamol or MDI Salbutamol Antibiotic therapy

management
PNEUMONIA
• Give oral Amoxicillin. Give the first dose at the clinic and teach the
mother how to give the other doses at home. Give 40 mg/kg/ dose
twice a day for 5 days.
• Encourage the mother to feed the child.
• When to return: Advise her to bring the child back after 2 days or
earlier if the child becomes sicker or is unable to drink or breastfeed

management
SEVERE PNEUMONIA
• Oxygen therapy
• Antibiotic therapy
✓Injection Ampicillin 50 mg/kg/ dose IM or IV every 6 hours.
✓Give injection Cloxacillin 25 mg/kg/dose every 6 hours if
staphylococcal pneumonia is suspected.

management
SEVERE PNEUMONIA
• Injection Gentamicin 5 mg/kg IM or IV once a day if the child is
severely malnourished.
• If the child does not show signs of improvement within 48 hours,
switch to Ceftriaxone 50 mg/ kg/dose twice daily or Cefotaxime 50
mg/kg/dose every 6 hours.
• Shift to oral drugs as soon as the child is able to take orally

management
SEVERE PNEUMONIA
• Supportive care
✓Remove any thick secretions at the entrance to the nasal passages or
throat, which the child cannot clear by gentle suction.
✓Manage fever. Provide maintenance IV fluid if child cannot accept
oral feeds.
✓ Stop IV fluids gradually when the child is accepting orally
satisfactorily.
✓If wheeze is present, give Nebulization Salbutamol

management
SEVERE PNEUMONIA
• Monitoring
The child should be checked by a nurse at least every 3 hourly and by a
doctor at least twice daily.
Monitor vitals, intake/ output. In the absence of complications, there
should be signs of improvement like breathing slower, less indrawing of
the lower chest wall, less fever, improved ability to eat and drink better
oxygen saturation in next 48 hours.

management
SEVERE PNEUMONIA
• Children with severe pneumonia can be discharged when: Respiratory
distress has resolved. There is no hypoxaemia (oxygen saturation ≥
90% on room air) They are feeding well. They are able to take oral
medication or have completed a course of parenteral antibiotics. The
family is counseled when to return.
• At discharge, give feeding advice, vaccinations that are due, address
risk factors like malnutrition, indoor air pollution and parental
smoking.

Introduction
• Tuberculosis is a specific infectious disease caused by Mycobacterium
tuberculosis.
• The disease primarily affects lungs and causes pulmonary tuberculosis.
7/3/2023 40

IntroductIon….
• It can also affect intestines, meninges, bones and joints, lymph glands,
skin and other tissues of the body.
7/3/2023 41

Epidemiology
• A total of 1.4 million people died from TB in 2019
(including 208 000 people with HIV).
• Worldwide, TB is one of the top 10 causes of death
and the leading cause from a single infectious agent
(above HIV/AIDS).
7/3/2023 42

EpIdEmIology….
• In 2019, an estimated 10 million people fell ill with
tuberculosis(TB) worldwide.
• 5.6 million men, 3.2 million women and 1.2
million children.
7/3/2023 43

EpIdEmIology….
• Multidrug-resistant TB (MDR-TB) remains a
public health crisis and a health security threat.
• A global total of 2,06,030 people with multidrug- or
rifampicin-resistant TB (MDR/RR-TB) were
detected and notified in 2019, a 10% increase from
1,86,883 in 2018.
7/3/2023 44

Epidemiology in Nepal
• Tuberculosis (TB) remains one of the major public
health problems in Nepal.
7/3/2023 45

Epidemiology in Nepal
• In Nepal, an estimated 69,000 fell ill with TB
during FY 2077/78.
• National Tuberculosis Programme registered 28,677
all forms of TB. (Nearly 58% missing cases)
7/3/2023 47

EpIdEmIology….
• TB cases were reported from all parts of the
country, but the Terai belt reported the highest
numbers of cases which is 60%
• The childhood TB cases reported are nearly 5.5%
of all cases which is still a huge challenge in Nepal.
7/3/2023 48

EpIdEmIology….
• Among the reported cases, male TB cases were
reported nearly 2 times more than female.
7/3/2023 49

EpIdEmIology….
• Nepal TB program is also missing out to find nearly
58% of estimated cases annually, which has played
a big role in control of TB program.
7/3/2023 50

EpIdEmIology….
• TB-HIV co-infection rate in Nepal is 1.1% (HIV
among TB) and
• HIV testing among TB patient are also improving
(18% of 2017 to 54% 2018).
7/3/2023 51

EpIdEmIology….
• Multidrug-resistant TB (MDR-TB) is another
challenge for the country.
7/3/2023 52

EpIdEmIology….
• The proportion of MDR-TB was 2.2% among new
cases and 15.4% among retreatment cases based
on DRS (Drug Resistant Survey) survey carried
out in 2011/12.
7/3/2023 53

National Tuberculosis
programme
Nepal aims to end tuberculosis epidemic by 2050
with the intermediate target of reducing TB incidence
by 20% by the year 2021 compared to 2015 and
increase case notifications by a cumulative total of
20,000 from July 2016 to July 2021.
7/3/2023 54

National Tuberculosis programme
• Targets linked to the SDGs and the End TB
strategy:
• Detect 100% of new sputum smear-positive TB
cases and cure at least 85% of these cases.
• Eliminate TB as a public health problem (<1 case
per million population) by 2050
7/3/2023 55

Natural History of Disease
i. Agent Factors
• Agent: M. tuberculosis is the causative agent of
tuberculosis.
7/3/2023 56

Natural History of Disease
Source of infection
a. Human
• Infected sputum
b. Bovine
• Infected milk
7/3/2023 57

Natural History of Disease….
• Communicability: Patient are infective as long as
they remain untreated.
• Effective anti-microbial treatment reduces
infectivity by 90% within 48 hours.
7/3/2023 58

ii. Host Factors:
• Age: It affects all ages. Majority of TB patients are in the productive
age group (25–64 years).
• Sex: More prevalent in males.
• Nutrition: Malnutrition is widely believed to predispose tuberculosis.
7/3/2023 59

• Immunity: Immunocompromised state increases the risk of infection.
• iii. Social factors:
7/3/2023 60

iv. Mode of transmission
• Tuberculosis is mainly transmitted by droplet infection and droplet
nuclei generated by sputum positive patients with pulmonary
tuberculosis.
7/3/2023 61

v. Incubation period
• 3-6 weeks.
7/3/2023 62

Sign and Symptoms
• Only about 10% of people infected with M. tuberculosis ever develop
tuberculosis disease.
• Many of those who suffer TB do so in the first few years following
infection, but the bacillus may lie dormant in the body for decades.
7/3/2023 63

Sign and Symptoms….
• Classic clinical features associated with active
pulmonary TB are:
➢Cough may be non-productive or mucopurulent
sputum may be expectorated (2 weeks or more)
➢Fatigue
➢Unintentional weight loss/anorexia
7/3/2023 64

Sign and Symptoms….
➢Fever and night sweats
➢hemoptysis
7/3/2023 65

Extra Pulmonary TB
• Common forms of extra- pulmonary TB are skeletal
TB, tubercular meningitis, genito-urinary TB, and
gastro-intestinal TB.
• Patient usually presents with features like fever,
night sweats, weight loss and local features related
to the site of disease.
7/3/2023 66

Extra Pulmonary TB…
• Many patient with extra-pulmonary TB also have
co-existent pulmonary TB.
• If a patient has extra-pulmonary TB, look for
pulmonary TB, send sputum samples for AFBs and
if sputum AFBs are negative, do a chest x-ray.
7/3/2023 67

The Control of Tuberculosis
• The control measures consist of:
a. Curative component - Case finding and treatment;
b. Preventive component - BCG vaccination.
7/3/2023 68

The Control of Tuberculosis…
1. Case detection
• A person with cough for 2 (two) weeks or more is a
presumptive TB patient and must have a sputum
examination.
7/3/2023 69

1. Persons to be evaluated for TB both adults and
children are the following:
• Signs and symptoms suggestive of TB
• Household or other close contacts of bacteriologically
confirmed pulmonary TB
7/3/2023 70

• Chest X-ray suggestive of any lung field abnormality
(including TB)
7/3/2023 71

• Routine screening of patients with illness who are at
high risk for TB includes the followings.
1. HIV positive patients
2. Patients on long term steroid therapy
3. Diabetic patients
4. Cancer patients
7/3/2023 72

5. Severe Acute Malnutrition (SAM)
6. Symptomatic moderate acute malnutrition (MAM)
7. Elderly
7/3/2023 73

The Control of Tuberculosis….
• Case Finding Tools
(i) Xpert MTB/RIF : is the rapid molecular test,
currently recommended by WHO (first-line
diagnostic for TB diagnosis).
• It can provide results within 2 hours.
• Since 2013, it has also been recommended for use in
children and to diagnose specific forms of
extrapulmonary TB.
7/3/2023 74

• The test has much better sensitivity than sputum smear microscopy.
• Xpert MTB/RIF test can detect TB and rifampicin-resistant TB
7/3/2023 75

Case Finding Tools
ii. Sputum smear microscopy
• Direct sputum smear examination should be done for all patients with
presumptive TB where Xpert MTB/RIF is not available.
7/3/2023 76

7/3/2023 77

Case Finding Tools
iii. Sputum culture and DST.
• All patients with Rifampicin resistant TB identified by Xpert
MTB/RIF should have specimen sent for TB culture and DST and
LPA where applicable.
7/3/2023 78

Case Finding Tools
iv. Line Probe Assay
• LPA is a PCR based test used for diagnosis of TB and for determining
susceptibility to different anti TB drugs.
• It needs higher bacterial load in samples than for Xpert MTB/RIF for
a positive result and hence smear-positive samples and cultures are
preferred
7/3/2023 79

Case Finding Tools
v. Chest X-Ray
• It help in assessing the extent of lung damage in complicated cases
but not for a diagnosis.
7/3/2023 80

• Globally, use of rapid molecular tests is increasing, and many
countries are phasing out the use of smear microscopy for
diagnostic purposes (although microscopy and culture remain
necessary for treatment monitoring).
7/3/2023 81

Treatment
• The best way to ensure effective treatment for TB
patients is to support medicine intake through Directly
Observed Treatment (DOT) using fixed-dose
combination tablets.
• All TB treatment must be given under DOT
7/3/2023 82

thE control of tubErculosIs…
• There is now only one category of treatment for TB
patients needing first-line treatment.
• All TB patients whether bacteriologically confirmed
or clinically diagnosed will receive Treatment
Regimen (2HRZE (intensive phase /4HR
(continuation phase)).
7/3/2023 83

thE control of tubErculosIs…
7/3/2023 84

• In patients who require TB re-treatment, drug
susceptibility testing should be conducted to inform
the choice of treatment regimen.
7/3/2023 85

• It is very important that all TB patients MUST RECEIVE
SUPERVISED TB TREATMENT OR DOT (Directly Observed
Treatment).
7/3/2023 86

The Control of Tuberculosis
Community-Based DOT:
• any TB patients who cannot attend to the TB Treatment Centre
regularly
• such patients will be treated in the community closed to their home by
a community volunteer.
7/3/2023 87

Drugs for TB
• First-line drugs – INH (H), Rifampicin (R), Pyrazinamide (Pz),
Ethambutol (E)
• Second line – Levofloxacin/Moxifloxacin (Lfx/Mfx), Linezolid (Lz),
Clofazimine (Cfz), Amikacin (Am), Para Aminosalicylic Acid (PAS),
Ethionamide (Eto), etc
7/3/2023 88

Preventive component
• BCG vaccination
• The aim of BCG vaccination is to induce a benign, artificial
primary infection which will stimulate an acquired resistance to
possible subsequent infection with virulent tubercle bacilli,
• Thus reduce the morbidity and mortality from primary
tuberculosis among those most at risk.
7/3/2023 89

Drug resistant TB
• Drug Resistant TB (DR TB) is TB that is resistant to
TB drugs.
• Resistance can be developed to one or more TB
drugs (1st or 2nd line drugs).
• MDR TB and other drug resistant TB result from
poor management of susceptible TB
7/3/2023 90

Drug resistant TB….
• Ensuring all TB patients complete TB treatment
under supervision (DOT) is the most effective way
to ensure TB patients are successfully treated and
that drug resistant strains of TB are not created.
7/3/2023 91

• Xpert MTB/RIF test is used to detect:
a. For assessing multi drug resistance TB
b. Diagnosis of TB & assessing rifampicin resistance
c. Monitoring drug response in MDR TB
d. Assessing isoniazid resistance
ANS: b

National Tuberculosis programme targets to eliminate TB as a public
health problem by the year:
a. 2030
b. 2025
c. 2050
d. 2040
ANS: c

Water borne diseases
Deepa Manandhar
Lecturer
Community Health Nursing

introduction
• Drinking water is a major source of microbial pathogens in developing
countries
• Water borne disease cause more than 2 million deaths and 4 billion
cases of diarrhoea annually.

Water borne diseases
• Diseases caused by ingestion of water contaminated by human or
animal faeces or urine, which contain pathogenic microorganisms.
• Many bacteria, viruses, protozoa and parasites can cause disease when
ingested.
• The majority of these pathogens derive from human or animal faeces,
and are transmitted through the faecal-oral route.

typhoid
• Typhoid is also known as enteric fever
• It is an acute illness associated with fever caused by Salmonella typhi
bacteria.

Problem statement
• WHO estimates the global typhoid fever disease burden at 11-20
million cases annually, resulting in about 128 000–161 000 deaths per
year.
• Typhoid risk is higher in populations that lack access to safe water and
adequate sanitation. Poor communities and vulnerable groups
including children are at highest risk.
-WHO 2018

Agent factors
a) AGENT : Typhoid is caused by Salmonella Typhi. It is readily killed
on heating on 60 degree Celsius for 15 minutes on boiling. It can
survive in ice for considerable time and for some days in fresh water. S.
typhi has three main antigens-O, H and Vi

Agent factors
(b) RESERVOIR OF INFECTION : Man is the only known reservoir of
infection, viz cases and carriers.
Convalescent carriers: excrete bacilli for 6-8 weeks
Chronic carrier: excrete bacilli for >1 year after clinical attack.

Agent factors
(c) SOURCE OF INFECTION : The primary sources of infection are
faeces and urine of cases or carriers; the secondary sources
contaminated water, food, fingers and flies.

Host factors
(a) Age : Typhoid fever may occur at any age. Highest incidence of this
disease occurs in the 5-19 years of age group.
(b) Sex: More cases are reported among males than females. But carrier
rate is more in females.

Environmental factors
• Observed throughout the year.
• Peak incidence is reported during July-September. This period
coincides with rainy season and an increase in fly population.
• Outside the human body, the bacilli are found in water, ice, food, milk
and soil for varying period of time.

Incubation period
• Usually 10-14 days.

transmission
• Typhoid fever is transmitted via the faecal-oral route or urine-oral
routes

Clinical features
▪ “Pea soup diarrhoea”
▪ the fever rise daily in a step ladder pattern during the first week,
remains continuously high during the second and third weeks and
comes down gradually by the fourth week.
▪ Later, splenomegaly, abdominal distension, tenderness, relative
bradycardia and occasionally meningismus appear.

Clinical features
▪ The rash (rose spots), is a pink papule 2 to 3 mm in diameter that
fades on pressure is found principally on the trunk which commonly
appears during the 2nd week of disease and disappears by 3-4 days.

treatment
• Typhoid fever can be treated with antibiotics.
• As resistance to antibiotics has emerged including to
fluoroquinolones, newer antibiotics such as cephalosporins and
azithromycin are used in the affected regions.

Prevention and control
• There are generally three lines of defence against typhoid fever :
1. control of reservoir
2. control of sanitation
3. immunization.
• The weakest link in the chain of transmission is sanitation which is
amenable to control.

Control of reservior
• The usual methods of control of reservoir are their identification, isolation,
treatment and disinfection.
i)Early diagnosis : This is of vital importance as the early symptoms are non-
specific. Culture of blood and stools are important investigations in the diagnosis of
cases.
(ii) Notification: This should be done where such notification is mandatory.
(iii) Isolation: Since typhoid fever is infectious and has a prolonged course, the
cases are better transferred to a hospital for proper treatment, as well as to prevent
the spread of infection.

Control of reservior
(iv) Treatment : The fluoroquinolones are widely regarded as the drug of choice for·
the treatment of typhoid fever. They are relatively inexpensive, well tolerated and
more rapidly and reliably effective than the former first-line drugs, viz.
chloramphenicol, ampicillin, amoxicillin and trimethoprim – sulfamethoxazole.
(v) Disinfection: Stools and urine are the sole sources of infection. They should be
received in closed containers and disinfected. . All soiled clothes and linen should be
soaked in a solution of 2 per cent chlorine and steam-sterilized.

Control of sanitation
• Protection and purification of drinking water supplies, improvement of basic
sanitation, and promotion of food hygiene are essential measures to interrupt
transmission of typhoid fever.
• Sanitary measures, not followed by health education may produce only temporary
results. However, when sanitation is combined with health education, the effects
tend to be cumulative, resulting in a steady reduction of typhoid morbidity

immunization
• A complementary approach to prevention is immunization.
• It is recommended to: those living in endemic areas, household
contacts, groups at risk of infection such as school children and
hospital staff, travelers proceeding to endemic areas, and those
attending melas and yatras.

immunization
• A new typhoid conjugate vaccine, with longer lasting immunity, was
prequalified by WHO in December 2017.

immunization
• With support from Gavi, the Vaccine Alliance, WHO, UNICEF and
other partners, the Government of Nepal today launched a new
vaccine campaign introducing Typhoid Conjugate Vaccine (TCV) into
the routine immunisation programme across the country.

immunization
• Three week campaign of Typhoid conjugate vaccine was done from 7th
April to 1 may 2022 with the aim to reach all children between 15
months and 15 years to quickly achieve wider protection from typhoid.
• The campaign aims to reach 95% coverage of nearly 7.5 million
children with the typhoid conjugate vaccine (TCV) and simultaneously
identify ‘zero-dose’ children and those that have missed other routine
vaccines.

introduction
• Cholera is an acute diarrhoeal disease caused by caused by bacteria
Vibrio cholera.
• The infection spreads through contaminated water, food and drinks.
Eating and drinking utensils washed with contaminated water are the
vehicles for transmission of cholera.

Problem statement
• Researchers have estimated that each year there are 1.3 to 4.0 million
cases of cholera, and 21 000 to 143 000 deaths worldwide due to
cholera

Problem statement
• Nepal is endemic for cholera with the potential for large outbreaks.
• Outbreaks of cholera are reported in different regions of the country
every year, causing the location of outbreaks difficult to predict.
• On May 4, 2009, a cholera death was reported in Jajarkot District.
• The research team found found 12,500 cases and 128 deaths

Problem statement
• As of 5 th September 2022 , a total of 76 cases of Cholera had been
reported in Nepal from Kathmandu, Lalitpur, Bhaktapur, Nuwakot and
Dhading.

Epidemiological determinants
(a)AGENT : Vibrio cholerae.
(b)RESERVOIR OF INFECTION: The human being is the only known
reservoir of cholera infection. He may be a case or carrier.
(a)INFECTIVE MATERIAL : The immediate sources of infection are
the stools and vomit of cases and carriers.

Host factors
a) AGE AND SEX : Cholera affects all ages and both sexes. In endemic
areas, attack rate is highest in children.
(b) POPULATION MOBILITY: Movement of population (e.g., pilgrimages,
marriages, fairs and festivals) results in increased risk of exposure to
infection.

Host factors
(c) ECONOMIC STATUS : incidence of cholera tends to be the highest in
the lower socio-economic groups, and this is attributable mainly to poor
hygiene
(d) IMMUNITY: An attack of cholera is followed by immunity to
reinfection, but the duration and degree of immunity are not known.
Vaccination gives only temporary, partial immunity for 3-6 months

Faecally contaminated water
Contaminated food and drinks
Direct contact

Clinical features
• abrupt onset of vomiting and purging of large amounts of rice water
stools
• Thirst
• Sunken eyes
• Pale skin
• cold and clammy extremities
• rapid and feeble pulse
• muscular cramps

control of Cholera
• Early case finding
• Oral rehydration therapy (ORS)
WHO recommended formula:
The World Health Organization recommends solutions containing 2.6 g
sodium chloride, 2.9 g trisodium citrate dihydrate, 1.5 g potassium
chloride, and 13.5 g anhydrous glucose, all dissolved in 1 L of clean
water for a total osmolarity of 245 mOsm/L solution.

control of Cholera
• Antibiotics should be given as soon as vomiting has stopped
• commonly used antibiotics for the treatment of cholera are
flouroquinolones, tetracycline, Azithromycin, ampicilline and
Trimethoprim TMP-Sulfamethoxazole (SMX).
• Sanitation measures
✓Water control
✓Excreta disposal
✓Food sanitation
✓disinfection

control of Cholera
• Chemoprophylaxis:
✓drug of choice is Tetracycline
✓Mass chemoprophylaxis is not advised for total community; only
advisable for household contacts.
✓To prevent one case of cholera, 10,000 persons need to be given
chemoprophylaxis.
• Health education most effective prophylactic measure
• Vaccination: Cholera vaccine is a killed vaccine, gives only partial
protection.

The usual incubation of typhoid fever is:
a. 10-14 days
b. 3-5 days
c. 21-25 days
d. 7-14 days
ANS: a

Reservoir of typhoid fever is:
a. Birds
b. Pigs
c. Cattle
d. Man
ANS: d

Freshly prepared ORS should not be used after:
a. 6 hours
b. 12 hours
c. 18 hours
d. 24 hours
ANS: d

• Which of the following is drug of choice for chemoprophylaxis of
cholera
a. Tetracycline
b. Doxycycline
c. Azithromycin
d. Co-trimoxazole
ANS: a

• For controlling an outbreak of cholera, all of the following measure
are recommended except
a. Proper disposal of excreta
b. Mass chemoprophylaxis
c. Chlorination of water
d. Early detection and management of cases
ANS: b

rabies
▪ Rabies, also known as hydrophobia is an acute, highly fatal viral
disease of the central nervous system, caused by Lyssavirus type 1.

agent
▪ The causative agent (Lyssavirus type 1) belongs to the family
rhabdoviridae.

Source of infection
▪ The source of infection to man is the saliva of rabid animals.

Reservoir of infection
▪ The virus is found in the salivary glands and central nervous system of
dogs and other rabid animals. It is excreted in saliva and urine.
▪ Dog is the major reservoir for the majority of cases of human rabies.

Host factor
▪ All warm blooded animals including man are susceptible to rabies.
Rabies in man is a dead-end infection

▪ People are infected following a deep bite or scratch by an infected
animal. Dogs are the main host and transmitter of rabies. They are the
source of infection in almost all the rabies deaths annually in Asia and
Africa.

Clinical features
• Fever, severe headache, anxiety and restlessness for a day or two.
1. Prodromal stage
• Restlessness increases. Hydrophobia
• Patient is intolerant to noise, bright light or a cold draught of air
2. Stage of invasion
• General paralysis, hemiplegia or paraplegia develop
3. Stage of paralysis

prevention
1. Prevention of disease in man
2. Control of disease in dogs

prevention
The indication and procedure for PEP depend on the
• type of contact with the suspected rabid animal and
• immunization status of the patient

WHO classification of exposure

prevention
PEP (Post exposure Prophylaxis) by category of exposure
• Category I: No PEP required
• Category II: Wound Washing and immediate vaccination
• Category III: Wound Washing and immediate vaccination and RIG (Rabies
Immunoglobulins) administration.

prevention
Local Wound Treatment
❖ All bite wounds and scratches should be attended to as soon as possible after
exposure.
❖ Thorough washing and flushing of the wounds for approximately 15 minutes
with soap or detergent and plenty of water is required.
❖ If soap and detergent are not immediately available, wash with running water for
15 minutes.
❖ It should be noted that the immediate washing of the wound is a priority. The
maximum benefit of the wound washing is obtained when fresh wound is cleaned
immediately.

prevention
❑Local Wound Treatment
❖ All bite wounds and scratches should be attended to as soon as possible after
exposure.
❖ Application of local remedies on the wounds should be strongly discouraged.
❖ If local irritants like herbs, oil, chilli or turmeric powder have been applied, these
should be removed by thorough washing of the wounds.
❖ After wounds have been washed, local antiseptics (viricidal topical preparation)
like Povidone Iodine should be applied on the wounds.

prevention
❑RIG
▪ The role of RIG in passive immunization is to provide neutralizing antibodies at
the site of exposure before patients start producing their own antibodies as a result
of vaccination.
▪ Rabies immunoglobulin should be given with the first dose of vaccine into and
around the wound site.
▪ It is not indicated beyond the seventh day

prevention
❑Rabies Vaccine
• All animal bite victims of Category II and III exposures, irrespective of age and
body weight, require the same number of injections and dose per injection
• The WHO approved regimen for intradermal route is the 1-week, 2- site regimen
(2-2-2-0-0). This regimen is evidence based, saves time and ensures compliance.
• The Government of Nepal has recommended this schedule to be used in the
country.

prevention
▪ 0.1ml of reconstituted vaccine is administered per ID site. 0.1ml. is
injected into the upper layer of the skin over the deltoid area of one
arm. Similarly, 0.1ml. is injected in the other arm.

Intradermal IPC vaccine regimen
▪ The WHO has recently recommended the new IPC (Institut Pasteur du Cambodge)
postexposure vaccine regimen consisting of 0.1 mL ID injection at 2 sites on days
0, 3, and 7.

MCQ
Post exposure prophylaxis of rabies is given on:
a. Days 0,3,7,14
b. Days 0,3
c. Days 0,3,7
d. Days 0,7,14
ANS: 0,3,7

MCQ
A patient present with dog bite in the palm fingers and oozing of blood
on the neck regions, belongs to which class of the exposure:
a. Class I
b. Class II
c. Class III
d. None
ANS: c

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