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Infectious

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Title: Infectious


1
Infectious Communicable Diseases
  • Chemeketa Community College

2
Are we at risk?
  • Patient contact
  • Co-workers
  • Hygiene
  • Hazardous scenes

3
Overview
  • Infectious diseases affect entire populations
  • Important to understand population demographics
  • Their ability to move internationally
  • Age distributions
  • Socioeconomic considerations
  • Genetic factors
  • Study of an infectious disease cluster is
    regional consequences may be international.
  • Think of consequences of person-to-person
    contacts

4
World map according to land mass
5
World According To Global Population
6
World Map Showing People With HIV
7
Reflections of Health Care Spending
8
Public Health Agencies
  • Local thats YOU!
  • State
  • Health dept
  • Federal
  • US DHS CDC P
  • Monitors
  • Studies researches
  • Manages
  • OSHA

9
Agency responsibility relative to isolation from
exposure
  • Exposure plan
  • Maintenance and surveillance
  • Appointing a DO
  • Schedule of standards implemented
  • PPE
  • gloves
  • protective eyewear
  • face shields
  • masks
  • gowns

10
  • BSI
  • Procedures for evaluation of circumstances and
    counseling
  • Personal, building, vehicular, equipment
    disinfection and storage
  • Correct handling
  • Correct disposal
  • After action analysis

11
Guidelines, Recommendations, Standards, Laws
  • PPE must be available to all employees at high
    risk
  • All employees must be offered HB vaccine
  • All high risk employees must be offered
    protection from bloodborne pathogens including TB
    testing, measles vaccination.

12
Host Defense Mechanisms
  • Nonspecific and surface defense mechanisms
  • Flora
  • Enhances effectiveness of surface barrier by
    interfering with establishment of agents
  • Can be responsible for infection
  • Skin
  • Intact skin defends against infection by
  • Maintaining an acidic pH level
  • Preventing infection

13
Host Defense Mechanisms cont.
  • Gastrointestinal (GI) System
  • Resident bacterial flora provides competition
    between colonies of microorganisms for nutrients
    and space helps prevent proliferation of
    pathogenic organisms
  • Stomach acid may destroy some microorganisms
  • Eliminates pathogens through feces

14
Host Defense Mechanisms cont.
  • Upper Respiratory system
  • Turbinates
  • Mucous
  • Mucociliary escalator
  • Normal bacterial flora
  • Lymph tissues of tonsils and adenoids permit
    rapid local immunological response

15
Host Defense Mechanisms cont.
  • Genitourinary (GU) tract
  • Natural process of urination and bacteriostatic
    properties of urine help prevent establishment
    of microorganisms in GU tract
  • Antibacterial substances in prostatic fluid and
    vaginal fluid help prevent infection in GU system.

16
Host Defense Mechanisms cont.
  • Internal Barriers
  • Protect against pathogenic agents when external
    lines of defense are breached.
  • Include
  • Inflammatory response
  • Immune response

17
Inflammatory response
  • A local reaction to cellular injury
  • Generally protective and beneficial
  • May initiate destruction of the bodys own tissue

18
Three separate stages
  • Cellular response to injury
  • Decreasing energy stores
  • Cell membrane deteriorates, begin to leak
  • Vascular response to injury
  • Capillary permeability increases, edema
  • Leukocytes collect
  • Phagocytosis
  • Leukocytes engulf, digest, destroy invaders

19
Immune response
  • Possesses self-non-self recognition
  • Produces antibodies-------
  • Some lymphocytes become memory cells
  • Is self-regulated to activate only with invading
    pathogens

IgG IgM IgA IgD IgE
20
Immune response cont.
  • B-cells
  • Produces antibody
  • T-cells
  • Processes antigen for B-cell,
  • Killer T cells are stimulated to multiply by
    presence of antigens on abnormal cells
  • Helper T cells turn on activities of killer cells
  • Suppressor T cells turn off action of helper and
    killer T cells
  • Inflammatory T cells stimulate allergic
    reactions, anaphylaxis, autoimmune reactions

21
Approach to a call
  • Wear appropriate PPE
  • Patient Assessment
  • Focused history and physical
  • History of present illness
  • Onset - gradual or sudden?
  • Fever
  • Antipyretic usage (ASA, APAP)
  • Neck pain or rigidity?
  • Difficulty swallowing, secretions?
  • How did sx change over time?

22
Approach to a call cont.
  • Past medical history
  • Chronic infections, inflammation
  • Use of steroids, antibiotics
  • Organ transplant and associated medicines
  • Diabetes or other endocrine disorders
  • COPD or respiratory complications

23
Detailed History and Physical
  • Assess skin for temperature, hydration, color,
    mottling, rashes, and petechiae
  • Assess sclera for icterus
  • Assess patient reaction to neck flexion
  • Assess for lymphadenopathy in neck
  • Assess digits and extremities for purulent lesions

24
After the Call
  • Upon disposition of patient, dispose of supplies,
    bag linen, disinfect ambulance and equipment
  • Reprocessing methods for EMS durable equipment
  • Sterilization
  • High-level disinfection
  • Intermediate-level disinfection
  • Low-level disinfection

25
Stages of an infectious disease
Stage of Disease Begins Ends
Latent period With invasion When agent can be shed
Communicable period When latent period ends Continues as long as agent is present
Disease period Follows incubation period Of variable duration
26
The Ryan White Act
  • Ryan Wayne White - 1971 1990
  • Dx - Hemophilia at 3 days old
  • Tx - Factor VIII and blood transfusions
  • 1984 Dx - AIDS
  • 1990, 1996, 2000, 2006 Ryan White law passed

27
What does it mean?
  • Funding for HIV/AIDS treatment
  • Health care provider employees must be notified
    within 48 hours if an exposure is found to have
    occurred.
  • Employers must name a DICO to coordinate
    communications between hospital and agency

28
Ryan White Act - 2006
  • Staffers removed provisions of bill dealing with
    Emergency Responders
  • Hospitals no longer required to test or reveal
    results within 48 hours
  • Efforts to reinstate underway

29
Individual Responsibilities
  • Be familiar with laws, regulations
  • Proactive attitude infection control
  • Maintain personal hygiene
  • Attend to wounds
  • Effective hand washing after every patient
    contact
  • Remove or dispose of work garments- handle
    uniforms properly

30
Individual Responsibilities
  • Handle and launder soiled work clothes properly
  • Prepare food and eat in appropriate areas
  • Maintain general and psychological health
  • Dispose of needles and sharps appropriately
  • Dont wipe face and/or rub eyes, nose, mouth etc.

31
Pathophysiology
  • Infectious Agent
  • Virulence
  • Dosage
  • Means of Transmission
  • Direct
  • Indirect
  • Host
  • Host Resistance
  • Protective Measures
  • Routes of Exposure
  • Airborne
  • Bloodborne
  • Foodborne
  • (Fecal/Oral)

32
Whats That Mean
  • Exposure does not necessarily equal infection
  • The chain of elements must be intact
  • Transmission can be controlled

33
Well talk about...
  • HIV
  • Hepatitis A
  • Hepatitis B
  • Hepatitis C
  • Hepatitis non-ABC
  • Tuberculosis
  • Meningococcal meningitis
  • Pneumonia
  • Rabies
  • Hantavirus
  • Chicken pox
  • Mumps

34
And these too
  • Rubella
  • Measles
  • Whooping cough
  • Influenza
  • Mononucleosis
  • Herpes simplex
  • 1 2
  • Syphilis
  • Gonorrhea
  • Chlamydia
  • Scabies Lice
  • Lyme disease
  • Gastroenteritis

35
Infectious agents
  • Bacteria
  • Prokaryotic
  • Nuclear material is not contained within a
    distinctive envelope
  • Self-reproducing without host cell BUT require
    host for food, support
  • S/S depend on cells and tissues infected

36
  • Toxins - often more lethal than bacterium
  • Endotoxins
  • Exotoxins
  • Can be localized or systemic infection

37
  • Viruses
  • Eukaryotic
  • Nuclear material contained within a distinct
    envelope
  • Must invade host cells to reproduce
  • Cant survive outside of host cell

38
Other Microorganisms
  • Prions
  • Slow viruses particles of protein
  • Accumulate in nervous tissue and brain tissue
  • Mad Cow Disease
  • Fatal familial insomnia
  • Alzheimers Disease
  • Parkinsons Disease

39
  • Fungi
  • Protective capsules surround the cell wall and
    protect fungi from phagocytes
  • Broad-spectrum antibiotics can cause fungal
    infections
  • Pneumonia
  • Yeast infections

40
ProtozoansSingle-celled microorganismsMore
complex than bacteria
  • Live in soil opportunistic infections
    fecal-oral or mosquito bites
  • Malaria
  • Some forms of Gastroenteritis
  • Trichomoniasis (STD)

41
Parasites Helminths (worms)
  • Roundworms
  • Live in intestinal mucosa
  • S/S abdominal cramping, fever, cough
  • Pinworms
  • Common in US
  • 20 of children in temperate
  • climates are infected
  • Live in distal colon
  • S/S anal itching
  • Hookworms
  • 25 world population rare in US
  • Walking barefoot in contaminated area
  • S/S epigastric pain, anemia

42
Human Immunodeficiency Virus (HIV) - Slim Disease
  • Present in blood and serum-derived body fluids
  • Directly transmitted person-person
  • Indirectly transmitted via
  • Blood transfusion, organ transplant, contaminated
    needles

43
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44
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45
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46
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47
Spread of AIDS in Africa
48
  • Various stats about Africa- Sub-Saharan Africa
    has 10 percent of the worlds population but is
    home to more than 60 percent of all people living
    with HIV and AIDs- In 2005, 3.2 million people
    in the region became newly infected, while 2.4
    million adults and children died of AIDs
  • Likelihood of contacting the HIV virus per 10,000
    exposures
  • Blood Transfusion 9,000 - 90 chance, Childbirth
    2,500 - 25 Chance, Needle-sharing injection drug
    use 67 - 0.67 Chance, Percutaneous needle stick
    30 - 0.3 Chance, Anal intercourse 50 - 0.5
    Chance, Penile-vaginal intercourse 10 - 0.1
    Chance, Oral intercourse 1 - 0.01 Chance
  • Many countries have over 15 of their adult
    population carrying the virus.
  • Swaziland - People Living with HIV/Aids 220,000
    - Population with HIV/Aids 38.8
  • Botswana - People Living with HIV/Aids 350,000 -
    Population with HIV/Aids 37.3
  • Lesotho - People Living with HIV/Aids 320,000 -
    Population with HIV/Aids 28.9
  • Zimbabwe - People Living with HIV/Aids 1,800,000
    - Population with HIV/Aids 24.6
  • South Africa - People Living with HIV/Aids
    5,300,000 - Population with HIV/Aids 21.5
  • Namibia - People Living with HIV/Aids 210,000 -
    Population with HIV/Aids 21.3
  • Zambia - People Living with HIV/Aids 920,000 -
    Population with HIV/Aids 16.5
  • Malawi - People Living with HIV/Aids 900,000 -
    Population with HIV/Aids 14.2
  • United States - People Living with HIV/Aids
    984,000 - Population with HIV/Aids 0.6

49
Statistics
  • US- gt1,185,000 through 2003
  • Most 25-49 y/o
  • 24-27 undiagnosed HIV
  • 2005- est. 45,669 AIDS dx
  • Oregon 5,855 through 2005
  • 2005 284 new cases (AIDS primary Dx)
  • New York, California, Florida leading

50
As of the end of 2006
  • 44 million people worldwide were living with
    HIV/AIDS.
  • 3.5 million of these are children
  • Approx. 50 of adults living with HIV/AIDS
    worldwide are women.
  • 6.5 million HIV infections worldwide occurred in
    2005 alone - 18,000 day.
  • 40,000 new HIV infections/yr in the U.S, half are
    younger than 25 years of age (70 men, 30
    women).


51
By the end of 2006
  • 30 million people have died of AIDS worldwide.
  • 14 million orphans have been left behind.

52
AIDS Origins - First Reports
  • In Africa - First known case!
  • Man in Republic of Congo died in 1959, had his
    blood frozen for an immunology experiment.
  • In the U.S A 15-yr old male prostitute died of
    Kaposis Sarcoma in 1969.
  • Frozen tissue sample had HIV antibodies - not
    reported until 1999.
  • In Europe A Danish surgeon who had worked in
    Zaire. She died mysteriously in 1976.

53
First reports, cont.
  • June 1981 reports of new disease in male
    homosexual community in U.S.
  • 5 men in LA area diagnosed with PCP (pneumocystis
    carinii pneumonia), a type of pneumonia carried
    by birds.
  • Very unusual, since PCP is usually only found in
    profoundly immune-suppressed patients.

54
First Reports (Cont.)
  • July 1981 reports of Kaposis sarcoma (KS),
    a very uncommon cancer, found in 26 gay men in
    NYC and California.
  • Very unusual, since KS had only been seen in
    older men of Jewish or Italian ancestry (mostly
    in lower legs).

55
At the same time
  • 1982 Similar cases outside the U.S. (Zambia,
    Uganda).
  • 1983 Zaire.
  • Soon cases were identified in all Western
    European countries and in Australia, New Zealand,
    and parts of Latin America (Brazil, Mexico).

56
Origins of AIDS - What we know
  • There are two types of the virus HIV-1 and
    HIV2.
  • HIV-1 appears to have spread from Central
    Africa.
  • HIV-2 has so far been confined mainly to West
    Africa.
  • 9 of the 11 known sub-types are found in the
    Republic of Congo ? probable origin.

57
  • Causative agent - HIV-1 HIV-2
  • Seeks cell receptor CD4 T cells
  • Found on surface of T helper cells
  • Both types are seriologically distinct but share
    similar characteristics

HIV infected T-cell
58
Origin of HIV-1
  • Cross-species transmission from chimpanzee (Pan
    troglodytes troglodytes).
  • Simian virus closely related to HIV jumped from
    monkeys to humans, later mutated into current
    form SIVcpz.
  • Genetic evidence (75-85).
  • Several species of monkey carry HIV-like simian
    viruses. Believe virus jumped at least 8 times
    from ape to human.


59
Origin of HIV-1, cont.
  • Consumption of bushmeat
  • The slaughter and selling of monkey body parts
    provides families with meat and income.
  • This is a long-standing practice - but has
    decreased in the past few decades due to
  • Commercial logging driving out animals.
  • Bans on hunting/trading simian body parts
  • Better roads, easier access to other food.


The blood-to-blood contact of killing these
animals is a prime suspect in humans
acquiring the HIV virus.
60
  • HIV-1 is far more pathogenic most cases
    world-wide are HIV-1, Group M
  • First case in US of HIV-1, Group O, identified in
    6/96
  • HIV-antibody tests in US detect HIV-1 Group M,
    with 99 accuracy HIV-1 Group O with 50-90.
  • HIV-2 milder symptoms, slower development
    mainly in West Africa. US cases 79

61
Why The Rapid Spread?
  • International Travel
  • 'Patient Zero - Gaetan Dugas
  • Analysis of several of the early cases of AIDS
    -infected individuals were either direct or
    indirect sexual contacts of the flight attendant.
  • The Blood Industry
  • In some countries such as the USA paid donors
    were used, including intravenous drug users.
  • This blood sent worldwide.
  • Also, in the late 1960's hemophiliacs benefit
    from Factor VIII. To produce the coagulant, blood
    from thousands of individual donors had to be
    pooled.

62
Why The Rapid Spread?
  • Drug Use
  • The 1970s - increase in availability of heroin
    following the Vietnam War and other conflicts in
    the Middle East,
  • The development of disposable syringes and the
    establishment of 'shooting galleries' provided
    another route.
  • What other theories have there been about the
    origin of HIV?
  • Conspiracy theories - manufactured by the CIA vs
    genetically engineered.

63
  • Occurrence highest
  • High-risk sexual behavior
  • IV drug and steroid abuse
  • Transfusion recipient between 1978-1985
  • Hemophilia or other coagulation disorders
    requiring blood products
  • Infant born from HIV-positive mother
  • Other factors
  • Coexisting STDs (esp. with ulceration)
  • Penile foreskin

64
Why all the fuss over AIDS?
  • AIDS is killing over 3 million people each year
    worldwide. No other disease is spreading at this
    rate.

65
Why all the fuss over AIDS?
  • It has an extraordinary capacity for change and
    rapid global spread. Hard to make a vaccine.
  • There is a long asymptomatic period between
    infection and illness. Can be passed on during
    this period. Many people with disease seem
    outwardly healthy.

66
Why all the fuss over AIDS?
  • HIV/AIDS is more serious than many common
    diseases because of the age groups it attacks.
  • Mainly kills people in their 20s to 40s ?
    societys most productive group.
  • 40 increase in 14-22 age group
  • 70 are unknown carriers
  • Death of these young people has left behind 14
    million AIDS orphans.

67
Why all the fuss over AIDS?
  • Therapy
  • HIV/AIDS requires the use of some of the most
    EXPENSIVE and TOXIC drugs in medical history.
  • 2,000 - 4,000 per month
  • Need to be 98 compliant to be effective

68
  • Initial case definition established by CDC in
    1981.
  • 1987 1993 s/s include tuberculosis, recurrent
    pneumonia, wasting syndrome, HIV dementia,
    sensory neuropathy.

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70
Classifications Categories
  • Category A
  • Acute retroviral infection
  • 2-4 weeks after exposure
  • Mono-like illness lasts 1 2 weeks
  • Fever
  • Adenopathy
  • Sore throat

71
  • Transient decrease in CD4T cell counts
  • Seroconversion 6-12 weeks after transmission
  • CD4T cell count return to normal levels
  • Asymptomatic infection persistent generalized
    lymphadenopathy gradual decline in CD4T cell
    count

72
  • Category B
  • Early symptomatic HIV
  • Decreased CD4T cell count
  • Common complications
  • Localized Candida infections
  • Oral lesions
  • Shingles
  • PID
  • Peripheral neuropathy
  • Fever/Diarrhea lasting more than one month

73
  • Category C
  • Late symptomatic HIV
  • Represents all AIDS-defining diagnoses
  • CD4T cell count 0 to 200 per uL
  • Severe opportunistic infections
  • Bacterial pneumonia (Pneumocystis Carinii
    Pneumonia)
  • Pulmonary tuberculosis
  • Debilitating diarrhea
  • Tumors in any body system, including Kaposis
    sarcoma
  • HIV-associated dementia
  • Advanced HIV CD4T cell counts 0-50 per uL.

74
  • Nervous system - toxoplasmosis of CNS
  • Immune system - major site of compromise
  • Respiratory system - pneumocystis carinii
    pneumonia
  • Integumentary system - Karposis sarcoma

75
  • 13-30 transmission to infants born to
    HIV-infected mothers
  • Breast feeding can result in HIV transmission
  • Virus has occasionally been found in saliva,
    tears, urine, bronchial secretions.
  • Vector transmission has not been known to occur.
  • Risk of oral sex is not quantified believed low.

76
Patient management
  • Out-of-hospital care - supportive.
  • BSI as appropriate
  • Effective hand washing
  • Use of eye protection, masks and gowns highly
    recommended when exposure to large volumes of
    body fluids.

77
  • HCW infection
  • Non-intact skin exposure (6/2000)

    56 138 ?
  • Susceptibility and resistance
  • Infectiousness may be high during initial period
    after infection and at end-stage
  • Race and gender are not risk factors for
    susceptibility.

78
  • Care in use of medical equipment mandatory
  • Disinfection of equipment mandatory
  • Early diagnosis, treatment, counseling for
    health-care providers is mandatory.

79
HIV testing
  • OraQuick Rapid HIV 1 / 2 test
  • Oral fluid, plasma, whole blood
  • 20 40 minutes
  • Accuracy
  • Positive 99.3
  • Negative 99.8

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81
Post-exposure prophylaxis
  • lt 72 hours non-occupational exposure
  • Highly active antiretroviral therapy (HAART)
  • PMPA (tenofovir) 28 days
  • Repeat testing 4-6 weeks after exposure again at
    3 months, 6 months, 1 year

82
WHO Recommendations for a First Line Regimen in
Adults and Adolescents
  • d4T3TCNVP
  • ZDV3TCNVP
  • d4T3TCEFZ
  • ZDV3TCEFZ
  • d4T (NRTI) alternative name Stavudine
  • ZDV (NRTI) alternative names Zidovudine or AZT
  • EFZ (NNRTI) alternative name Efavirenz
  • NVP (NNRTI) alternative name Nevirapine
  • 3TC (NRTI) alternative name Lamivudine

83
Hepatitis
  • A viral disease
  • Produces pathologic alterations in the liver

84
Hepatitis-A
  • Causative agent-Hepatitis A virus
  • Most common type of viral hepatitis
  • Once infected, person is immune to HAV for life

85
Statistics
  • Oregon 2005 1.3/100,000 (49 new cases)
  • 1955 86.7/100,000
  • Marion County 632
  • Multnomah County 1,512
  • National 1/3 of Americans show past infection
    (immunity)

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  • Many infections asymptomatic
  • Liver may be affected
  • Often occurs without jaundice, esp. children
  • Only recognizable by liver function studies
  • Only hepatitis virus that does not lead to
    chronic liver disease or chronic carrier state.

88
  • Routes of transmission
  • Stool of infected person
  • Contaminated water, ice or food
  • Sexual and household contact can spread virus
  • Can survive on unwashed hands for 4 hours

89
Susceptibility and resistance
  • No clearly defined populations at increased risk.
  • 75 of people with H-A have sx.
  • In developing nations with poor sanitation,
    infection is common
  • In developed nations, often associated with day
    care, nursing homes

90
S/S
  • Onset is abrupt with fever, weakness, anorexia,
    abdominal discomfort, nausea and darkening of
    urine, sometimes followed w/in a few days by
    jaundice/icterus.
  • Mild severity lasting 2-6 weeks.
  • Rarely serious.

91
Patient management
  • Care is supportive for fluid intake and
    prevention of shock.
  • Person is most infectious during first week of
    symptoms
  • BSI mandatory.

92
Immunization
  • Prophylactic IG may be administered within two
    weeks after exposure
  • If traveling to Africa, the Middle East, Central
    and South America, Asia - get immunized.

93
  • Hepatitis A vaccine available for 2 y/o or older
  • Close contact with people who live in areas with
    poor sanitary conditions
  • Male-male sex
  • Illicit drugs
  • Children in populations with repeated epidemics
  • Chronic liver disease or clotting factors
    disorders

94
Hepatitis-B
  • Causative agent - H-B virus.
  • Potential secondary complication - liver necrosis
  • HBV usually lasts lt 6 months
  • Carrier state may persist for years

95
Statistics
  • National 60,000 new infections (2004)
  • Oregon 2005 99 cases acute HB
  • 404 cases chronic carriers
  • Marion County 195
  • Multnomah County 556

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97
Routes of transmission
  • Blood, semen, vaginal fluids, saliva, blood
    transfusion, dialysis, needle and syringe
    sharing, tattooing, sexual contact, acupuncture,
    communally-used razors and toothbrushes.
  • HBV stable on environmental surfaces gt 7 days
  • Transmission by insects and fecal-oral route
    not demonstrated.

98
S/S
  • Within 2-3 months, infected persons gradually
    develop non-specific symptoms such as anorexia,
    n/v, fever, joint pain, generalized rashes,
    sometimes jaundice.
  • Risk of developing chronic infection varies
    inversely with age.

99
  • 1 of patients develop full-blown liver crises
    and die with mortality increasing gt 40 y/o.
  • 5-10 infected people become asymptomatic
    carriers.

100
Patient management
  • Out-of-hospital - supportive
  • BSI
  • Effective handwashing
  • Care in use of equipment.
  • Careful handling of sharps
  • High-level disinfection of equipment esp.
    laryngoscopy blades is mandatory.

101
Immunizations
  • Recombivax HB and
  • Engerix B are effective.
  • Vaccines initial, one-month, six-month provide
    long-lasting immunity in 95-98 of cases.
  • Postexposure prophylaxis
  • HBV vaccine
  • HB IG

102
Hepatitis C
  • Causative agent - H-C virus.
  • Organ affected - liver.
  • Most frequent infection secondary to needlestick
    sharp injury
  • 85 infected healthcare workers become chronic
    carriers

103
  • Health care workers - 2.7 - 10 probability of
    infection when exposed to contaminated blood.
    Transmission by household and sexual contact low.
  • Cant occur from food and water.

104
Statistics
  • Oregon 2005 newly reportable 1,337 July-Dec.
    (chronic) 50 acute cases
  • Marion County 4
  • Multnomah County 17
  • National new infections per year has declined
    (240,000 in 1980s 24,000 in 2004)

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106
S/S
  • Same as for HBV but less progression to jaundice
  • Chronic liver disease common with gt80 developing
    chronic liver disease.
  • Apparent association between HCV infection and
    liver cancer

107
  • Patient management
  • Same as for HBV
  • Immunization
  • Prophylactic administration of IG not supported
    by current data
  • Post exposure testing important
  • Vaccine may be available

108
Hepatitis non-ABC
  • Hepatitis D infects a cell with other hepatitis
    virus
  • When virus active in HBV patients, resulting
    disease extremely pathogenic
  • Hepatitis E not bloodborne is spread like H-A

109
  • Hepatitis G - newly identified
  • Major epidemics documented in young adults.
  • Women in 3rd trimester especially susceptible to
    liver disease

110
S/S
  • Onset abrupt with s/s resembling HBV
  • Always associated with HBV
  • Patient management
  • Same as for HBV
  • Immunization
  • HB vaccine can indirectly prevent H-D, but has no
    effect on H-E.

111
Tuberculosis
  • Causative agent - mycobacterium tuberculosis
  • 8 million new TB/yr worldwide
  • 3 million die of disease

112
  • TB Epidemic in US
  • Immigration
  • Transmission in high-risk environments
  • Prisons, homeless shelters, hospitals, nursing
    homes
  • National 1953 84,350 19,707 deaths
  • 2005 14,097 662 deaths
  • Oregon 106/100,000 (11/03)
  • 103 - 2005

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  • Rate of TB for HIV patients 40x rate of TB for
    non-HIV persons
  • Routes of transmission
  • Airborne droplet
  • Prolonged exposure to infected person
  • Reservoirs include some cattle, badgers, swine

115
Susceptibility and resistance
  • Period of incubation 4-12 weeks.
  • Period for development of disease 6-12 months
    after infection.
  • Risk of developing disease highest in children lt
    3, lowest in later childhood and high among
    adolescents, young adults and elders.
  • High in immuno-compromised patients
    HIV-infected, underweight, undernourished.

116
S/S
  • First infection usually subclinical
  • These bacteria lie dormant but can reactivate
    into secondary TB
  • Most common site of reactivation TB is in apices
    of lungs.
  • Patients present with
  • chronic productive/non-productive cough
    (persistent for 2-3 weeks),
  • low-grade fevers,
  • night sweats,
  • weight loss, fatigue
  • Hemoptysis common.

117
  • Body systems affected
  • Indirectly affects respiratory system including
    larynx
  • Left untreated, TB can spread to other organ
    systems and cause other sx.
  • Cardiovascular pericardial effusions may develop
  • Skeletal
  • Generally affects thoracic and lumbar spine,
    destroying intervertebral discs
  • Chronic arthritis of one joint is common
  • CNS
  • Causes a subacute meningitis and forms granulomas
    in brain

118
Patient care
  • Primarily supportive
  • Prevent shock

119
  • Routine evaluation of Health care workers
  • PPD (purified protein derivative)
  • Positive reaction indicates past infection
  • CXR
  • Sputum stain and culture
  • Remember TB is communicable with prolonged
    exposure to droplet infection.

120
Drug therapy
  • Prophylactic INH recommended routinely for
    persons lt35 y/o who are PPD positive not
    recommended gt 35 due to hepatic complic.
  • Therapeutic Isoniazid, Rifampin, Pyrazinamide,
    Streptomycin
  • Side effects of INH
  • Paresthesias, seizures, orthostatic hypotension,
    N/V, Hepatitis

121
Meningococcal meningitis
  • Causative organism Neisseria meningitidis,
    meningococcus
  • Tissues affected
  • Colonize lining of throat and spread easily
    through respiratory secretions
  • Est. 2-10 of population carriers, but are
    prevented from illness by throats epithelial
    lining.

122
Statistics
  • Oregon 2005 56 cases
  • Oregon 1994 2003 887
  • Marion County 111
  • Multnomah County 182

123
  • Modes of transmission direct contact w/
    secretions during intubation, suctioning, CPR
    etc.

124
S/S
  • Onset is rapid
  • Fever
  • Chills
  • Joint pain
  • Neck stiffness or nuchal rigidity
  • Petechial rash
  • Projectile vomiting
  • Headache

125
  • 10 may develop septic shock acute adrenal
    insufficiency, DIC, coma may result. Death may
    occur in 6-8 hours.

126
  • Pediatric patients infants 6 mo - 2 y/o esp.
    susceptible maternal antibodies protect neonates
    to 6 mo.
  • Infants display nonspecific s/s
  • Fever,
  • Vomiting,
  • Irritability,
  • Lethargy,
  • Bulging fontanelle
  • High-pitched cry

127
  • Patient management
  • Protective measures with surgical masks to
    patient.
  • Prophylactic tx available rifampin, etc.
  • Immunizations especially for older children and
    adults.

128
Other infectious agents cause meningitis
  • Streptococcus pneumoniae (bacterial)
  • 2nd most common cause in adults
  • Most common cause of pneumonia in adults and OM
    in children
  • Spread by droplets, prolonged contact or soiled
    linen.

129
  • Hemophilus influenza type B (bacterial)
  • Gram negative rods. Prior to 1981, leading cause
    of meningitis in children 6 mo-3 y/o.
  • Although tx with antibiotics very effective, gt50
    infected children have long-term neurological
    deficits.
  • Implicated in epiglottitis, septic arthritis,
    generalized sepsis.

130
  • Viruses (aseptic meningitis)
  • A variety known to cause meningitis
  • Not considered communicable

131
Pneumonia
  • Causative organisms
  • Bacterial
  • Viral
  • Fungal

132
Pneumonia (cont)
  • Systems affected
  • Respiratory - pneumonia
  • CNS - meningitis
  • ENT - otitis, pharyngitis media
  • Routes of transmission
  • Droplet, Direct contact, Soiled linen

133
Susceptibility
  • Pulmonary edema
  • Flue
  • Exposure to inhaled toxins
  • Chronic lung disease and aspiration
  • Geriatrics
  • Pediatrics with low birth weight and
    malnourishment

134
Other high-risk groups
  • Sickle cell disease
  • Cardiac disease
  • Diabetes
  • Kidney disease
  • Hiv
  • Organ transplants
  • Hodgkins disease
  • Asplenia

135
Statistics
  • 2005 (Tri-county area) 165 cases
  • Death highest in gt 84 y/o

136
S/S
  • Sudden onset chills, high-grade fevers, chest
    pain with respirations, dyspnea.
  • PEDS fever, tachypnea, chest retractions are
    ominous.
  • Purulent exudates may develop in one or more
    lobes.
  • Patient may have productive cough with
    yellow-green phlegm.

137
Patient management
  • Several antibiotics effective to treat bacterial
    pneumonia
  • Protective measures for health-care workers.
  • Immunizations
  • Vaccine exists for some causes

138
Tetanus
  • Causative organism
  • Clostridium tetani
  • Live mainly in soil and manure
  • Also found in human intestine

139
Statistics
  • 500,000 cases/year worldwide
  • 45 mortality
  • 100 cases/year in U.S.
  • Patients gt 50 y/o
  • Oregon 1992-2001 6
  • Marion County 1997 1

140
  • Affects musculoskeletal system
  • Mode of transmission
  • Wounds, burns, other disruptions in skin.
  • Puncture wounds introducing soil, street dust and
    animal or human feces.
  • Dead or necrotic tissue favorable environment.

141
S/S
  • Muscular tetany
  • Painful contractions, esp. trismas or lockjaw and
    neck muscles secondarily of trunk muscles.
  • PEDS abnormal rigidity may be first sign.
  • Painful spasms with risus sardonicus
  • Can lead to respiratory failure.

142
Patient management
  • Support vital functions
  • Valium for muscle spasms
  • Consider paralytics
  • Magnesium sulfate
  • Narcotics
  • Antidysrhythmics
  • Administration of antitoxin - TIG

143
  • Post exposure of tetanus immune globulin - keep
    immunizations UTD.
  • Immunizations Booster before elementary school,
    every ten years thereafter.

144
Rabies - hydrophobia
  • Acute viral infection of the CNS
  • Causative organism - rabies virus
  • Affects nervous system
  • Route of transmission
  • Saliva from bite or scratch of infected animal.
  • Person-person transmission theoretically
    possible.
  • Airborne spread in bat caves - rare

145
Statistics
  • Oregon 1994 2003 77
  • Marion County
  • 1996 2
  • 1998 2
  • 2001 1
  • 2007 4 animals (bats)

146
  • Hawaii is only area in US that is rabies-free.
  • Wildlife rabies (in us) common in
  • Skunks
  • Raccoons
  • Bats
  • Foxes
  • Dogs
  • Wolves
  • Jackals
  • Mongoose
  • Coyotes.

147
  • Susceptibility Mammals highly susceptible.
  • Incubation period usually 3-8 weeks (rare 9 days
    - can be as long as 7 years).

148
S/S
  • Sense of apprehension
  • H/A
  • Fever
  • Malaise
  • Poorly defined sensory changes.
  • Progresses to weakness or paralysis
  • Spasm of swallowing muscles (causes hydrophobia)
  • Delirium
  • Convulsions
  • W/O medical care, disease lasts 2-6 days often
    results in death.

149
Patient management
  • EMS workers transmission never documented.
  • After bite
  • Thorough debridement of wound
  • Free bleeding and drainage.
  • Vigorously clean wound with soap and water and
    irrigate with 70 alcohol.
  • Prophylactic Tetanus vaccine
  • Administration of human rabies immune globulin
  • Over several weeks

150
Hantavirus
  • Known to be associated with hemorrhagic fever
    with renal syndrome occurs in Asia.
  • Also associated with a syndrome of severe
    respiratory distress shock in Southwestern U.S.
  • Deermouse
  • Transmitted via inhalation of aerosols of rodent
    urine and feces

151
Statistics
  • Oregon 1993 2003 5 cases
  • 2006 7 cases
  • NM 2006 68 cases

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S/S
  • Typically healthy adults
  • Onset of fever and malaise 1 5 weeks later
  • Followed several days later by respiratory
    distress
  • Fever,
  • Chills
  • H/A
  • GI upset
  • Capillary hemorrhage
  • Kidney failure, hypotension, severe infection may
    ensue
  • Death from poor cardiac output

154
Severe HPS
Evolution of HPS
2
1
3
Large effusion assoc. w/ HPS
155
Patient management
  • Supportive
  • BSI

156
Chickenpox
  • Causative agent variella-zoster virus (member of
    the Herpes virus group).
  • System affected primarily integumentary

157
Statistics
  • 4 million/yr in US
  • Most 1 4 y/o
  • Associated with Daycare

158
  • Shingles is a local manifestation of reactivation
    of latent viral infection
  • Mainly airborne
  • Soiled linen implicated.
  • Incubation period 10-21 days

159
S/S Chickenpox
  • More severe in adults
  • Begins with respiratory symptoms, malaise,
    low-grade fever.
  • Rash begins as small red spots that become raised
    blisters on a red base. Eventually dry into
    scabs. Rash is profuse on trunk
  • Itching
  • Patient management
  • Isolation until all lesions are crusted and dry.

160
  • Disease self-limited
  • Complications
  • Secondary bacterial infections
  • Aseptic meningitis
  • Mononucleosis
  • Reye syndrome

161
Mumps
  • Causative agentMumps virus
  • Acute, communicable systemic viral disease
  • Glands most commonly affected
  • Parotid
  • Testes
  • Pancreas

162
S/S
  • Mode of transmission droplet spread, direct
    contact
  • Incubation period 12-25 days.
  • Immunity general after recovery
  • 30 asymptomatic
  • Fever, swelling and tenderness of salivary
    glands, esp. parotid.
  • After onset of puberty
  • Orchitis
  • Testicular atrophy

163
Patient management
  • EMS workers - MMR immunity
  • Patients wear masks
  • Caution with soiled linen

164
Rubella (German measles)
  • Causative agent - rubella virus
  • Mild, febrile, highly communicable disease
  • Systems affected
  • Integumentary,
  • Musculoskeletal,
  • Lymph nodes

165
Mode of transmission
  • Maternal transmission gravest risk
  • Congenital heart diseases, eye inflammations,
    retardation,
  • Deafness (90 of neonates born to mothers
    infected in first trimester develop congenital
    rubella syndrome).

166
  • Congenital anomalies death from heart disease,
    sepsis in first 6 month
  • Mental retardation
  • Deafness
  • Person-person contact via mucous secretions

167
S/S
  • Generally mild fever, flue sx, red rash that
    spreads from forehead to face to torso to
    extremities and lasts 3 days.
  • Serious complications do not occur in Rubella.

168
Patient management
  • BSI including mask.
  • All EMS workers, especially females should be
    screened for immunity.
  • No specific treatment.
  • Immunizations known to be 98-99 effective

169
Measles (rubeola, hard measles)
  • Causative organism - measles virus
  • Highly communicable
  • Systems affected respiratory, CNS, pharynx,
    eyes, systemic
  • Mode of transmission - air droplets, direct
    contact.

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S/S
  • Prodrome - conjunctivitis, swelling of eyelids,
    photophobia, high fevers to 105 degrees, hacking
    cough, malaise

172
  • A day or two before rash, patients develop small,
    red-based lesions with blue-white centers in the
    mouth (Kopliks spots) sometimes disappearing
    with generalized skin rash.
  • Rash is red, slightly bumpy and spreads from
    forehead to face, neck, torso, to feet by 3rd day.

173
  • Rash usually lasts for 6 days, initially appears
    thicker over head and shoulders, clears up and
    follows that pattern toward feet.
  • Pneumonia, eye damage and myocarditis are all
    possible but most life-threatening is subacute
    sclerosing panencephalitis
  • Progressive deterioration of mental capacity,
    muscle coordination

174
Patient management
  • BSI, including mask
  • EMS workers should be immunized
  • No specific treatment.

175
Pertussis (Whooping Cough)The 100-day cough
  • Causitive organism - Bordetella pertussis
  • Mainly affects infants and young children
  • Affects oropharynx
  • Mode of transmission direct contact with
    airborne droplets.

176
S/S
  • Insidious onset of cough which becomes paroxysmal
    in 1-2 weeks, lasts 1-2 months.
  • Paroxysms are violent, inspiratory whoop. Whoop
    often not present in infants lt 6 mo., adults
  • Before pertussis vaccine in 1950s, disease
    killed more children in U.S. than all other
    infectious diseases combined

177
Patient management
  • EMS workers be cautious about handling linens,
    supplies etc. on all patients with hx of recent
    onset of paroxysmal cough
  • Transport patient with mask.
  • Communicable period thought to be greatest before
    onset of coughing.
  • Incubation period 6-20 days.
  • Erythromycin decreases period of communicability,
    but only reduces sx if given during incubation
    period.

178
Influenza the flu
  • Causative organisms influenza viruses types A,
    B, C
  • Affects respiratory system primarily
  • Mode of transmission airborne, direct contact
  • Virus can persist for hours, especially in low
    humidity and cold temp.
  • Incubation period 1-3 days.

179
S/S
  • URI- type symptoms which last 2-7 days.
  • Chills
  • Fever
  • Headache
  • Muscle aches
  • Anorexia
  • Fatigue
  • Cough often severe, protracted.

180
  • Patient management
  • Supportive
  • Immunizations
  • Health care workers should be immunized by
    mid-Sept. (flu season Nov.-Mar. in US).

181
Avian Flu
  • Lots of media coverage
  • In most bird populations
  • More of an issue when in domestic birds
  • Chickens
  • Turkeys
  • Ducks
  • Rarely transmitted to humans
  • Not known to transmit human to human
  • 50 death rate when acquired

182
27 February 2009
Cumulative Number of Confirmed Human Cases of
Avian Influenza A/(H5N1) Reported to WHO
Country   2003 2003 2004 2004 2005 2005 2006 2006 2007 2007 2008 2008 2009 2009 Total Total
Country   C D C D C D C D C D C D C D C D
Azerbaijan 0 0 0 0 0 0 8 5 0 0 0 0 0 0 8 5
Bangladesh 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0
Cambodia 0 0 0 0 4 4 2 2 1 1 1 0 0 0 8 7
China 1 1 0 0 8 5 13 8 5 3 4 4 7 4 38 25
Djibouti 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0
Egypt 0 0 0 0 0 0 18 10 25 9 8 4 4 0 55 23
Indonesia  0 0 0 0 20 13 55 45 42 37 24 20 0 0 141 115
Iraq 0 0 0 0 0 0 3 2 0 0 0 0 0 0 3 2
Lao People's Democratic Republic 0 0 0 0 0 0 0 0 2 2 0 0 0 0 2 2
Myanmar 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0
Nigeria 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1
Pakistan 0 0 0 0 0 0 0 0 3 1 0 0 0 0 3 1
Thailand 0 0 17 12 5 2 3 3 0 0 0 0 0 0 25 17
Turkey 0 0 0 0 0 0 12 4 0 0 0 0 0 0 12 4
Viet Nam 3 3 29 20 61 19 0 0 8 5 6 5 2 2 109 54
Total 4 4 46 32 98 43 115 79 88 59 44 33 13 6 408 256
C Cases D Deaths
183
West Nile Virus
  • Symptoms
  • Usually mild or no symptoms
  • May have fever
  • Headache
  • Body aches
  • Skin rash
  • Swollen lymph glands
  • May cause encephalitis

184
2005
185
2008
186
West Nile Virus
  • Treatment
  • Prevention
  • Insect repellent
  • Supportive
  • Most return to normal status within 1 year

187
Mononucleosis
  • Causative organism - Epstein-Barr virus or
    cytomegalovirus (both herpes virus family)
  • Body regions affected oropharynx, tonsils

188
  • Modes of transmission
  • Person-to-person spread by saliva
  • Kissing
  • Care providers to young children is common

189
S/S
  • Appear gradually
  • Fever
  • Sore throat
  • Oropharyngeal discharges
  • Lymphadenopathy
  • Splenomegaly
  • Recovery usually in a few weeks, but may take
    months

190
Patient management
  • No specific treatment
  • No immunization available.

191
Herpes simplex virus type 1
  • Causative organism HSV 1
  • Affects oropharynx, face, lips, skin, fingers,
    toes, CNS in infants
  • Mode of transmission
  • Saliva
  • Skin skin contact

192
S/S
  • Cold sores, fever blisters
  • Tx with acyclovir (Zovirax) helpful.

193
Patient management
  • BSI, including mask
  • Lesions are highly contagious

194
Herpes simplex virus type 2
  • Causative organism - HSV 2
  • Mode of transmission - sexual activity
  • S/S - Males
  • Lesions of penis, anus, rectum, and/or mouth

195
  • S/S - Females
  • Sometimes asymptomatic lesions of cervix, vulva,
    anus, rectum and mouth recurrent disease
    generally affects vulva, buttocks, legs, perineal
    skin.

196
Syphilis
  • Causative organism Treponema pallidum, a
    spirochete
  • Affects
  • Skin,
  • CNS,
  • Eyes,
  • Joints,
  • Skeletal system,
  • Kidneys,
  • Cardiovascular

197
Mode of transmission
  • Direct contact with exudates from moist, early,
    obvious or concealed lesions of skin and mucous
    membranes
  • Semen,
  • Blood,
  • Saliva,
  • Vaginal discharges,
  • Blood transfusions,
  • Needle sticks
  • Congenital transmission

198
S/S Occurs in 4 stages
  • Primary stage - painless lesion develops at point
    of entry called a chancre, 10-90 days after
    initial contact.
  • Lesion heals spontaneously within 1-5 weeks
  • Highly communicable at this stage

199
  • Secondary stage - bacteremia stage begins 2-10
    weeks after appearance of primary lesion
  • H/A
  • Malaise
  • Anorexia
  • Fever
  • Sore throat
  • Lymphadenopathy
  • Rash, (small, red, flat lesions) on palms and
    soles of feet, lasts about 6 weeks.

200
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201
  • Condyloma latum - painless wart-like lesion found
    on moist, warm sites like inguinal area.
    Extremely infectious, lasts _at_ 6 weeks.
  • Skin infection in areas of hair growth results in
    bald spots and/or loss of eyebrows.
  • CNS - eyes, bone and joints or kidneys may become
    involved.

202
  • Third stage - latent syphilis 1 40 years
  • 25 may relapse and develop secondary stage
    symptoms again.
  • After 4 years, there are generally no more
    relapses
  • 33 of patients will progress to tertiary
    syphilis the rest will remain asymptomatic.

203
  • Tertiary (Late) Syphilis
  • Granulomatous lesions (gummas) found on skin and
    bones skin gummas are painless with sharp
    borders bone lesions cause a deep, growing pain.
  • Cardiovascular syphilis occurs 10 years after
    primary infection generally results in
    dissecting aneurysm of ascending aorta or aortic
    arch. Antibiotics dont reverse this disease
    process.

204
  • Neurosyphilis asymptomatic, develop menengitis,
  • Spinal cord disease that results in loss of
    reflexes and loss of pain and temperature
    sensation.
  • Tabes dorsalis spinal column degeneration wide
    gait and ataxia
  • Spirochetes attack cerebral blood vessels and
    cause CVA.
  • Psychosis, Insanity

205
Late Stage Syphilis
206
Syphilis can do a number on your genitalia
Secondary syphilis w/gross disfiguration
207
  • Patient management
  • BSI
  • Causative agent extremely fragile and is easily
    killed by heat, drying, or soap and water.
  • Treatment is effective with penicillin,
    erythromycin, doxycycline.

208
US Syphilis Rates by State, 2004
209
Statistics
  • Oregon 2005 57 cases reported
  • 2004 58 cases reported
  • 115 increase over 2001

210
Gonorrhea
  • AKA The Clap
  • Causative agent Neisseria gonorrheae
  • Affect genital organs and associated structures
  • Mode of transmission direct contact with
    exudates of mucous membranes unprotected sex.

211
  • S/S - Males
  • Initial inflammation of urethra with dysuria and
    purulent urinary discharge . Left untreated, can
    progress to epididymitis, prostitis, and
    strictures of urethra.

212
Typical Gonorrheal penile discharge
213
  • S/S - Females
  • Dysuria and purulent vaginal discharge may occur.
  • Most females have no pain and minimal urethral
    discharge.

214
  • Infection of uterus can progress to PID fever,
    lower abdominal pain, abnormal menstrual
    bleeding, cervical motion tenderness.
  • Menstruation allows bacterial spread from cervix
    to upper genital tract - 50 of PID occurs within
    1 week of onset of menstruation.

215
  • Females at increased risk for sterility, ectopic
    pregnancy, abscesses of fallopian tubes, ovaries,
    peritoneum, and peritonitis.

216
  • Males and females
  • In rare cases, systemic bacteremia
  • Septic arthritis with fever, pain, swelling of 1
    or 2 joints can occur.
  • Patient management
  • BSI
  • Antibiotics

217
Statistics
  • Oregon
  • 1980 11,162
  • 1995 854
  • 2001 1,039
  • 2005 1,562

218
Gonorrhea Rates by State, 2004
219
Chlamydia
  • Causative organism Chlamydia trachomatis
  • Affects eyes, genital area and associated
    organs, respiratory system

220
  • Mode of transmission - sexual activity, sharing
    contaminated clothing or towels.
  • S/S similar to gonorrhea
  • Conjunctivitis may occur leading cause of
    preventable blindness in the world.
  • Infan
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