Florence V.Quintana RN
Communicable Disease = any disease that spreads from one host to another, either directly or indirectly Contagious Disease = disease that easily spreads directly from one person to another Infectious Disease = disease not transmitted by ordinary contact but require a direct inoculation through a break in a previously intact mucous membrane. On the other hand, all contagious diseases are infectious.
Examples of communicable diseases include herpes, malaria, mumps, HIV/AIDS, influenza, chicken pox, ringworm, and whooping cough. Cancer, on the other hand, is not a communicable disease.
Carrier is an individual who harbors the organism and is capable of transmitting it to a susceptible host without showing manifestations of the disease. Contact - is any person or animal who is in close association with an infected person, animal, or freshly soiled material
Based on Occurrence of Disease: 1. Sporadic Disease = disease that occurs only occasionally & irregularly with no specific pattern i.e. botulism, tetanus 2. Endemic Disease = constantly present in a population, country or community i.e. Pulmonary Tuberculosis; malaria
3. Epidemic Disease = patient acquire the disease in a relatively short period of time ; greater than normal number of cases in an area within a short period of time i.e, cholera; typhoid 4. Pandemic Disease = epidemic disease that occurs worldwide i.e. HIV infection; SARS
Based on Severity or Duration of Disease 1. Acute Disease = develops rapidly (rapid onset) but lasts only a short time i.e. measles, mumps, influenza
2. Chronic Disease = develops more slowly (insidious onset) disease likely to be continual or recurrent for long periods i.e. TB, Leprosy 3. Subacute Disease = intermediate between acute and chronic i.e. bacterial endocarditis 4. Latent Disease = causative agent remains inactive for a time but then becomes active to produce symptoms of the disease i.e. chickenpox shingles (zoster); amoebiasis
1. Primary Infection = acute infection that causes the initial illness 2. Secondary Infection = one caused by an opportunistic pathogen after primary infection has weakened the bodys defenses 3. Subclinical (Inapparent Infection) = does not cause any noticeable illness
Stages of Disease
Incubation Period
- time interval between the initial infection and the 1st appearance of any s/sx - patient is not yet aware of the disease Prodromal Period - early, mild appearance of symptoms of the disease Period of Illness Time of greatest symptomatic experience ( pt. is sick) - overt s/sx of disease WBC may increase or decrease can result to death if immune response or medical intervention fails
Period of Decline s/sx subside pathogen replication is brought under control vulnerable to secondary infection Period of Convalescence
regains strength and the body returns to its pre diseased state = recovery has occurred
Nurse Alert!!!!
Note that in the case of acquired immunity against a pathogen the progress of disease may end during the prodromal period as a consequence of the rapid immune system response to the infection. For example, acquired immunity might be as a consequence of vaccination or previous natural exposure to the pathogen.
Definitions: Symptoms subjective evidence of disease that is experienced or perceived subjective changes in body function noted by patient but not apparent to an observer Signs objective evidence of a disease the physician can observe and measure Syndrome a specific group of signs and symptoms that accompany a particular disease
Incidence the number of people in a population who develop a disease during a particular time period Prevalence = the number of people in a population who develop a disease, regardless of when it appeared = refers to both old and new cases
INFECTION - condition caused by the entry and multiplication of pathogenic microorganisms within the host body
Pathogenicity ability to cause disease Infective dose (sufficient number of microorganisms needed to initiate infection) Virulence ( disease severity) and Invasiveness of microorganisms ( ability to enter and move through tissue) Organisms specificity ( host preference) Resistance of the host Immunity of the host **Cycle of infection must be completed**
Chain of Infection
Chain of Infection
The chain begins with the existence of a specific pathogenic microorganism
The second link is the reservoir, an environment where the pathogen can survive.
Chain of Infection
The third link is the means of escape from the reservoir. ( Mode of Exit )
The fourth link is the mode of transmission from the reservoir to the host.
Chain of Infection
The fifth link is the means of entry into the host ( Mode of entry)
And the last link is the host's susceptibility to the pathogenic microorganism
Hand hygiene, first line of defense and the most important practice in preventing infection. Handwashing single most important way of preventing transfer of microorganisms
- is the condition of being secure against any particular disease, particularly the power which a living organism possesses to resist and overcome infection - is the resistance that an individual has against disease
IMMUNITY
IMMUNE SYSTEM
PROTECTION AGAINST INFECTIVE OR ALLERGIC DISEASES BY A SYSTEM OF ANTIBODIES, IMMUNOGLOBULINS AND RELATED RESISTANCE FACTORS. ANTIBODY - a specific immune substance produced by the lymphocytes of the blood of tissue juices of man or animal in response to the introduction into the body of an antigen
1.
1.
ANTIGEN TRIGGERING AGENT OF THE IMMUNE SYSTEM; FOREIGN SUBSTANCE INTRODUCED INTO THE BODY causing the body to produce antibodies TYPES OF ANTIGENS: INACTIVATED ( KILLED ORGANISM)
2. 3.
2. ATTENUATED ( LIVE WEAKENED ORGANISM) 1. single dose needed 2. long lasting immunity ** all vaccines lose their potency after a certain time.
TYPES OF IMMUNITY
NATURAL =innate; within the HOST; Immune System ACQUIRED = outside the HOST Natural = active or passive Artificial = active or passive
Types of Immunity
A. NATURAL : 1. Natural active through exposure or diseases; had the disease & recovered 2. Natural Passive maternal antibodies; acquired through placental transfer
B. ARTIFICIAL ( Laboratory )
1. Artificial active introduction of antigen Ex. Vaccines ; toxoids ( No exposure yet; preventive measure) = gives long immunity months to years 2. Artificial passive- introduction of antibodies Ex. Antitoxins; immunoglobulin ( gammaglobulin), antiserum, convalescent serum Ex. TAT ( tetanus antitoxin) ( w/ exposure to the causative agent) = gives short immunity 3-4 weeks
Immunity
ACQUIRED
1. NATURAL
2. ARTIFICIAL
( HUMAN)
( LABORATORY)
IMMUNIZATION
- is the induction or introduction of specific protective antibodies in a susceptible person or animal, or the production of cellular immunity in such a person or animal. - A PROCESS BY WHICH RESISTANCE TO AN INFECTIOUS DISEASE IS INDUCED OR AUGMENTED.
Active Immunization
1.
2.
3. 4. 5. 6. 7. 8. 9.
BCG DPT OPV/IPV Measles MMR TB Hepatitis B Varicella Hemophilus influenzae B (Hib)
2.
3. 4. 5. 6. 7.
Cholera vaccine Rabies Typhoid Influenza A & B Meningococcal Pneumococcal vaccine HPV vaccine
Passive immunization
1.
2.
3. 4. 5. 6. 7.
Diphtheria antitoxin Hepatitis B immunoglobulin (HBIG) Measles immunoglobulin Varicella immunoglobulin (VZIG) Rabies Human immunoglobulin (RIG) Tetanus human immunoglobulin (TIG) Tetanus Toxin ( ATS)
ALL VACCINE LOSE THEIR POTENCY AFTER A CERTAIN TIME. EXPIRY DATE SHOULD BE NOTED ON THE LABEL
Use water only in cleaning the refrigerator Or freezer. ( antiseptics, disinfectants and detergents Or alcohol lessen potency of vaccine )
Immunization
EPI : PPD 996 GOAL : universal child immunization ( Proc. No. 6) Common Goal to Prevent childhood diseases covered by the EPI ( expanded program immunization)
1. 2. 3.
4.
5. 6.
IMMUNOGLOBULINS ( IGS)
IgG
MOST PREVALENT ANTIBODY 80%, PRODUCED LATER IN THE IMMUNE RESPONSE, ONLY Ig THAT CAN CROSS PLACENTA
IgA
IgM IgE
PRINCIPAL ANTIBODY OF BLOOD, QUICKLY PRODUCED IN RESPONSE TO AN ANTIGEN, RESPONDS TO ARTIFICIAL IMMUNIZATION
RESPONDS TO ALLERGIC REACTION
IgD
DPT
MMR OPV Measles Hep B
6 weeks
15 wks 6 weeks 9 mos At birth
IM
oral SQ IM
Special-use Vaccine
Meningoccocal Rabies Typhoid Japanese encep Pneumococcal Epidemic areas Exposures travellers travellers immunocompro SQ ID/IM IM SC IM/SQ None Local rxn Local rxn Anaphylactic Local rxn
Severe febrile illness Live virus vaccine are generally not administered with altered immune system Allergic reaction
Permanent C.I.
Allergy Encephalopathy without known cause Convulsion within 7 days after Pertussis vaccine
Temporary C.I
= any site where the pathogen can multiply or merely survive until it is transferred to the host
= principal living reservoir of human disease 1. Direct Transmission = usually associated with signs and symptoms 2. Carriers = harbor the pathogen without associated signs and symptoms
Susceptible Host
Cover mouth and nose ( coughing or sneezing) Limit number of persons in a room Removal of dirt and dust Open room to fresh air and sunlight Roll linens together Remove bacteria from the air (air filters)
Use high quality foods Proper refrigeration and storage of food Proper washing, preparing, and cooking of food Proper disposal of uneaten food Proper hand washing Proper disposal of oral and nasal secretion Cover hair and wear clean clothes and apron Provide periodic health exam for kitchen workers Keep cutting boards clean Prohibit anyone with respiratory or GIT disease from handling food Rinse and wash utensils with a temperature above 80C
Handling of Fomites
Use disposable equipments Sterilize or disinfect equipment Use individual equipment for each patient Use single use thermometers Empty bedpans and urinals properly and wash with hot water, store in dry ,clean area or storage Place used linens and personal care equipments, and soiled laundry in a bag
Medical Asepsis CLEAN TECHNIQUE: Involves procedures and practices that reduce the number and transfer of pathogens Will exclude pathogens ONLY Attained by: Frequent and thorough hand washing Personal grooming Proper cleaning of supplies and equipment Disinfection Proper disposal of needles, contaminated materials and infectious waste Sterilization
Surgical Asepsis STERILE TECHNIQUE : Practices used to render and keep objects and areas sterile Exclude ALL microorganism Attained by: Use strict aseptic precautions for invasive procedures Scrub hands and fingernails before entering O.R. Use sterile gloves, masks, gowns and shoe covers Use sterile solutions and dressings Use sterile drapes and create an sterile field Heat sterilized surgical instruments
Patient Care Equipment Prevent contaminating yourself or transfer microbes to others Properly clean, disinfect or sterilize Dispose single use items Linens Handled, transported and processed to prevent contamination and transfer of microorganisms Occupational Health and Blood borne Pathogens Never recap used needles Puncture resistant containers
2. Transmission-Based Precautions
The second tier of precaution Precaution are instituted for patients who are known to be or suspected of being infected with highly transmissible infection.
Airborne
Yes
No
No
Droplet
No
No
Contact
Yes
yes
yes
Isolation
- is a protective procedure that limits the spread of infectious diseases among hospitalized clients, hospital personnel, and visitors. It is the separation from other persons of an individual suffering from a communicable disease. - other terms are: protective aseptic technique or barrier technique.
freedom of movement of persons or animals which have been exposed to communicable disease / s for a period of time equivalent to the longest incubation period of that disease. Surveillance -
Strict isolation
Use mask , gown and gloves (MUST) Private room For highly contagious or virulent infections
2.
3.
4. 5. 6. 7.
Contact isolation Respiratory isolation TB isolation Enteric isolation Drainage/secretion precaution Universal precaution when handling blood and body fluids
Type : STRICT Purpose: Prevent Transmission of highly contagious or virulent infections spread by air and contact
Private Room necessary Hand Washing X Gown X Masks X Gloves X Articles Discard or bag and label and send for decontamination and reprocessing. Diseases requiring Isolation Diphtheria (pharyngeal) , Lassa fever, Smallpox , Varicella.
Specification:
Type :
Contact
Specification:
Private Room necessary Hand Washing X Gown wear if soiling is likely Masks wear in close contact with client Gloves wear if touching infective material. Articles Discard or bag and label and send for decontamination and reprocessing.
Diseases requiring Isolation Acute Resp. infection in infant and young children, Herpes simplex, Impetigo, multiple resistant bacterial infection.
Specification:
Private Room necessary Hand Washing X Gown not necessarily Masks wear in close contact with client Gloves not necessarily Articles Discard or bag and label and send for decontamination and reprocessing.
Type :
Tuberculosis
Specification:
Type : Enteric
Precautions
Purpose:
To prevent infections that are transmitted by direct or indirect contact with feces.
Specification: Private Room Indicated if clients hygiene is poor and there is risk of contamination with infective materials. Hand Washing X Gown wear if soiling is likely Masks not necessary Gloves wear if touching infective material Articles Discard or bag and label and send for decontamination and reprocessing.
Type : Drainage-
secretion precautions
material or
Private Room not necessary Hand Washing X Gown wear if soiling is likely Masks not necessary Gloves wear if touching infective material Articles Discard or bag and label and send for decontamination and reprocessing.
Type :
Purpose: To prevent infections that are transmitted by direct or indirect contact with blood or body fluid.
Reverse Isolation
Protective or neutropenic isolation Used for patients with severe burns, leukemia, transplant, immuno deficient persons, receiving radiation treatment, leukopenic patients Those that enter the room must wear masks and sterile gowns to prevent from introducing microorganisms to the room
Additional Pointers
Regarding Disposal Precaution Secretion: Patient should be instructed to expectorate into tissue held close to mouth. Suction catheters and gloves should be disposed of in impervious, sealed bags. Excretion: Strict attention should be paid to careful hand washing; disease can be spread by oral- fecal route. Blood: needles and syringes should be disposable. Used needles should not be recapped. They should be placed in a puncture-resistant container that is prominently labeled Isolation Specimens should be labeled Blood Precaution.
Environmental Control
Routine care, cleaning and disinfection of environmental surfaces PRECAUTIONS FOR INVASIVE PROCEDURES:
Prevent injuries caused by needles, scalpels and other sharps instrument or devices when cleaning used instrument, when disposing of used needles Do not recap used needles, bend , break nor remove
them from disposable syringes or manipulate them. Place sharps in puncture resistant containers If gloves tears or a needle-stick or other injury occurs, REMOVE the gloves, wash hands, and wash sites of the needle stick thoroughly then put new gloves
Report injuries and mucous membrane exposure to appropriate infection control officer.
Waste management
1. sharps 2.Solid infectious cotton swab, dressing 3. Anatomic Infectious placenta / organ 4.Solid non-infectious used IV / bottle IV 5.General waste scrap paper / food material
Philippines set-up
Green plastic bags are biodegradable wastes such as fruits and vegetables' peelings, leftover food flowers, leaves, and twigs.
Philippines set-up
INFECTIOUS DISEASE
INFECTIOUS DISEASES
CLASSIFIED AS:
Blood/ vector borne Enteric diseases Eruptive fever Respiratory diseases CNS infection Diarrheal Diseases EMERGING DISEASES
INFECTIOUS DISEASES
CLASSIFIED AS :
1.
2.
Enteric diseases
a. Typhoid fever b. Viral Hepatitis c. Schistosomiasis
3.
Eruptive fever
4.
Respiratory diseases
a. Pneumonia b. Diphtheria c. PTB d. Mumps
5. CNS Infections
6.Diarrheal diseases
Dengue Fever, H-Fever, Dandy Fever, Breakbone Fever, Phil Hemorrhagic fever
Acute Febrile Disease Flavivirus, dengue virus 1,2,3,4 Incidence: Rainy season, urban areas IP: 3 to 10 days ( average 4-6 days ** Life span of the mosquito is 4 months Pathognomonic sign: Hermans rash
THE DISEASE PRESENTS WITH FEVER AND HEMORRHAGIC MANIFESTATIONS AND LABORATORY FINDINGS OF THROMBOCYTOPENIA AND HEMOCONCENTRATION Pathogenesis 1. increased capillary fragility d/t immune complex reactions 2. thrombocytopenia d/t faulty maturation of megakaryocytes 3. decreased blood clotting factors
Dengue Fever, H-Fever, Dandy Fever, Breakbone Fever, Phil Hemorrhagic fever
- Day
biting mosquito ( they appear 2 hours after sunrise and 2 hours before sunset. Low flying ( Tiger mosquito white stripes, gray wings ) - Breeds on clear stagnant water
Fever
torniquet test Spontaneous bleeding (petechiae,purpura,ecchymoses,pistaxis, gum bleeding, hematemesis, melena) Laboratory: thrombocytopenia </= 100,000mm3, hemoconcentration- an increase of at least 20% in the hematocrit or its steady rise
Assessment: Tourniquet test (Rumpel Leedes test) screening test, done by occluding the arm veins for about 5 minutes to detect capillary fragility.
Keep cuff inflated for 6 10 minutes ( child); 1015 minutes ( adults) Count the petechiae formation 1 square inch ( 20 petechiae/sq.in)(+)TT
Grade I Dengue fever, saddleback fever plus constitutional signs and symptoms plus positive torniquet test Grade II Stage I plus spontaneous bleeding, epistaxis, GI, cutaneous bleeding Grade III Dengue Shock Syndrome, all of the following signs and symptoms plus evidence of circulatory failure Grade IV Grade III plus profound shock and massive bleeding, undetectable BP and pulse
Laboratory criteria DHF: Platelet count Thrombocytopenia <100,000 Hct increased by 20 % or more
1st 2 clinical criteria plus 2 laboratory criteria or rising Hct DHF( dengue hemorrhagic fever) Shock w/ high hematocrit and marked thrombocytopenia DSS ( dengue shock syndrome)
Other : PT (Prothrombin Time) APTT (Activated Partial Thromboplastin Time) Bleeding time Coagulation time Period of communicability pts. are usually infective to mosquito from a day before the febrile period to the end of it The mosquito becomes infective from day 8 to 12 after the blood meal & remains infective all throughout life
pathophysiology
DHF
Febrile phase 2-7 days
First 2 days Vascular injury Plasma leakage (+) petechiae , (+) TT
Dengue Fever Vector caries virus (AEDES aegypti) Bite host ( IP 3-10d)
s/sx : Fever , headache, myalgia ,anorexia Vomiting, sorethroat, rashes
IMPROVE
Dengue progress
Circulatory failure
-hypotension -narrow pulse pressure ,20mm Hg (shock)
death
S/sx: Mild dengue abrupt onset of fever, headache, muscle and joint pains, anorexia, abdominal pain. Petecchiae, Hermans rash (5th-7th day; purplish macules w/ blanched areas on extremities) Severe dengue DHF/DSS *TRIAD: fever, rashes and muscle pain Bleeding leading to hypovolemic shock
There is no effective antiviral therapy for dengue fever. Treatment is entirely SYMPTOMATIC Paracetamol for headache ( never give ASPIRIN) IVF for hydration & replacement of plasma BT for severe bleeding O2 therapy is indicated to all patients in shock Sedatives for anxiety & apprehension No IM injections Nasal packing with epinephrine Gastric lavage Giving cytoprotectors
Medical MX
Nursing Mx
Symptomatic tx Mosquito free environment to avoid further transmission of infection Keep patient at rest during bleeding episodes VS must be promptly monitored For nose bleeding, maintain pts position in elevated trunk, apply ice bag to bridge of nose Observe for signs of shock Restore blood volume ( supine with legs elevated)
C- hemically treated Mosquito Net L arvae eating fish Gold fish E nvironmental Sanitation 4 0 clock habit A antimosquito soap lanzones peeling N atural mosquito repellant Neem tree , eucalyptus
, oregano
PREVENTION
Cover water drums and water pails at all times to prevent mosquitoes from breeding. Replace water in flower vases once a week. Clean all water containers once a week. Scrub the sides well to remove eggs of mosquitoes sticking to the sides. Clean gutters of leaves and debris so that rain water will not collect as breeding places of mosquitoes. Old tires used as roof support should be punctured or cut to avoid accumulation of water. Collect and dispose all unusable tin cans, jars, bottles and other items that can collect and hold water
2. Self protection measures such as wearing of long sleeve shirts and long pants and using mosquito repellants are a must during daytime.
3. Seek early consultation when early signs such as fever and rashes set in 4. Say NO to indiscriminate fogging except for dengue outbreak
Malaria
Acute and chronic parasitic diseases Causative agent : Protozoa of genus Plasmodia 4 species of Protozoa: 1. Plasmodium falciparum ( malignant tertian) Most fatal ; common in the Philippines 2. Plasmodium vivax ( Benign tertian) Non-life threatening except for the very young & old ; manifest chills q48H on the 3rd day onward if untreated
Plasmodium malariae (Quartan) Less frequently seen ; non life threatening , fever & chills usually occur q72H usually on the 4th day after the onset 4. Plasmodium ovale rare
Vector: (night biting) Female anopheles mosquito or minimus flavirustris = infectious but not contagious = thrives in clear, free flowing shaded streams usually in the mountains = bigger in size than the ordinary mosquito = brown in color, usually does not bite a person in motion = assumes a 36 degree position when it alights on walls, trees, curtains and the like
Incubation Period: 1. 12 days for P. falcifarum 2. 14 days for P. vivax and Ovale 3. 30 days for P. malariae Period of Communicability: Untreated or insufficiently treated patient may be the source of mosquito infection for more than three years in P. malariae; one to two years in P. vivax; and not more than one year on P. falcifarum
Pathogenesis
Anopheles mosquito >> gets parasites in the blood of infected person >>parasites multiply in mosquito >>parasites invade the salivary gland of mosquito >> mosquito bites the individual & thus, injects the parasites >> parasites invade RBC where they grow & undergo asexual propagation >> RBC ruptures or bursts releasing tiny organisms ( MEROZOITES) >> merozoites invade new batch Of RBC to start another schizonic cycle
Pathology the most characteristic pathology of malaria is destruction of red blood cells, hypertrophy of the spleen and liver and pigmentation of organs. The pigmentation is due to the phagocytocis of malarial pigments released into the blood stream upon rupture of red cells
Malaria
Transmission :
PATHOPHYSIOLOGY :
produce zygotes
RBC decreases deformability and oxygen transport, increase adhesion and fragility leading to anemia
Clinical Manifestation
uncomplicated fever, chills, sweating every 24 36 hrs Complicated sporulation or segmentation and rupture of erythrocytes occurs in the brain and visceral organs. Cerebral malaria changes of sensorium, severe headache and vomiting seizures
Clinical manifestations :
MALARIA (Ague)
1.
Cold stage
Chilling sensation of the body ( 10-15 mins) Chattering of lips, shakes Keep the patient warm Hot water bath Expose to heat Warm drinks Last about 10-15min 2. . Hot stage (3-4Hrs) Recurring high grade fever , headache , abdominal pain and vomiting TSB , cold compress Light clothing,
MALARIA (Ague)
Clinical manifestation :
I. Cold stage ( 10-15mins) II. Hot stage (3-4Hrs) III. Wet stage Profuse sweating Keep patient comfortable Keep them warm and dry Increase fluid intake
Diagnostics: 1. Malarial smear - Peripheral blood extraction (extract blood at the height of fever or 2 hrs before chilling ( AGUE) 2. Rapid diagnostic test ( RDT) blood test for malaria conducted outside the lab & in the field- result is within 10-15 mins. This is done to detect malarial parasite antigen in the blood. Pathognomonic sign: Stepladder fever
Medical Mgmt: A. IVFs B. Anti- Malarial Drugs Chloroquine ( less toxic); Premaquine For chloroquine resistant plasmodium quinine Prophylaxis chloroquine or mefloquine, pyrimethamine/sulfadoxine (fansidar) C. Erythrocyte exchange transfusion for rapid production of high levels of parasites in the blood.
Nursing Considerations
If entering an endemic area, travellers are advised to take chloroquine from 1-2 weeks at weekly interval. Protection is good for 1 year Patient must be closely monitored Soaking of mosquito nets in an insecticide solution Bio pond for fish On stream clearing cut vegetation overhanging stream banks to expose the breeding stream to sunlight Vectors peak biting is at night (9pm-3am)
Planting of neem tree ( repellant effect) Zooprophylaxis ( deviate mosquito bite from man to animals Wear long sleeves/ pants/Socks Apply insect repellant on skin Screening of houses Notes: Malaria stricken mother can still breastfeed Chloroquine ca be given to a pregnant woman If there is drug resistance, give quinine SO4 BT in anemia Dialysis in renal failure Decreased fluids in cerebral edema No meds to destroy sporozoites
Category of provinces
Category A no significant improvement in malaria for the past 10 years. >1000 - Mindoro, isabela, Rizal, Zamboanga, Cagayan, Apayao, kalinga Category B - <1000/year - Ifugao, abra, mt. province, ilocos, nueva ecija, bulacan, zambales, bataan, laguna Category C significant reduction -pampanga, la union, batangas, cavite, albay
Extremely debilitating and stigmatizing disease caused by PARASITIC worm Affect men, women and children Causes extensive disability, gross disfigurement. CAUSATIVE AGENT: Wuchereria bancrofti ( african eye worm)
FILARIASIS
FILARIASIS
Parasitic disease caused by an african eye worm ( microscopic thread like worm)
Wuchereria bancrofti & Brugia malayi Wuchereria :Camarines norte/sur , albay , sorsogon , quezon , masbate , mindoro , romblon , marinduque , bohol , samar , leyte , palawan , sulu , tawi-tawi and basilan. Malayi : Palawan , eastern samar , agusan ,sulu
Filariasis ( elephantiasis )
Mosquito bites Aedes poiculus , culex faligans and anopheles flavirostris
Bites a person with lymphatic filariasis & infect the mosquito
Microscopic worms pass from mosquito Through the human skin, travel to LN , grow as adult
Adult worm lives for 7 yrs in lymph vessels Mate release into blood stream- microfilaria
Note: a person needs Many mosquito bite Over several months- years to get Filariasis
Assessment : s/sx
Chills, headache and fever between 3 months and 1 year after the insect bite Swelling redness and pain in arms ,legs or scrotum Areas of abscesses may appear as result of drying worm or secondary bacterial infection Lymphadenitis. Oophoritis, orchitis
of microfiliaria in fresh blood obtained between 10:00 to 2:00 am Patient s history must be taken and pattern of inflammation and signs of lymphatic obstruction must be Blood observed . /vector-borne
Treatment :
Drugs Ivermectin , albendazole and DIETHYLCARBAMAZINE (DEC)- 6mg/KBW in divided doses for 12 consecutive days Eliminate the larvae Impairing the adult worms ability to reproduce Kill the adult worm Surgery excision of subcutaneous nodule Elephantiasis of the legs elevate and provide elastic bandages
Management Guidelines
Supportive Therapy
Paracetamol Antihistamine for allergic reaction due to DEC Vitamin B complex Elevation of infected limb, elastic stocking
PREVENTIVE MEASURE
Health teachings Environmental Sanitation
Hygiene Provide mosquito nets Long sleeves, long pants & socks Mosquito repellant Take yearly dose of medicine that kills worms circulating in the blood Screening of houses
Weils disease, Mud fever, Trench fever, Flood fever, Spirochetal jaundice, Japanese 7 Days fever, Leptospiral jaundice, Hemorrhagic jaundice, Swine Herds disease, Canicola fever a zoonotic systemic infection caused by Leptospires, that penetrate intact and abraded skin through exposure to water, wet soil contaminated with urine of infected animals. Species: L. Manilae, L. Canicula, L. Pyrogens Incubation Period: 6-15 days
Spirochete, Leptospira interrogans, gram (-) Weils syndrome severe form MOT: Contact of skin or open wound from soil water contaminated with urine or feces of infected rats (main host) INGESTION OF CONTAMINATED FOOD/H2O
S/SX: Anicteric Type (without jaundice) manifested by fever, conjunctival infection signs of meningeal irritation
Icteric Type (Weil Syndrome) Hepatic and renal manifestation Jaundice, hepatomegally Oliguria, anuria which progress to renal failure Shock, coma, CHF Convalescent Period
Diagnosis
Blood: during the 1st week CSF: from the 5th to the 12th day Urine: after the 1st week until convalescent period
Treatment
Specific
Penicillin 50000 units/kg/day Tetracycline 20-40mg/kg/day
Non-specific Supportive and symptomatic Administration of fluids & electrolytes Peritoneal dialysis for renal failure
LEPTOSPIROSIS
JAUNDICE IS A BAD PROGNOSTIC SIGN CASE FATALITY RATE : 40%
Blood /vector-borne
Avoidance of exposure to urine & tissues from infected animals ( flood) Rodent Control Hygienic control in slaughterhouses, farmyard buildings & bathing pools Use of protective clothing & boots Primarily a disease of domesticated & wild animals transmitted via direct or indirect contact. It enters the skin, mucus membrane, conjunctiva, inhalation Disease is usually short lived & mild but severe infection can damage kidneys & liver
HEPATO-ENTERIC DISEASES
GIT
Typhoid Fever
Salmonella typhosa, gram (-) Carried only by humans Bacterial infection transmitted by contaminated water, milk, shellfish ( oyster ) & other foods Infection of the GIT affecting the lymphoid tissue ( payers patches) of the small intestine Most severe form of salmonellosis caused by salmonella typhi MOT: oral fecal route 5 Fs : Fingers, Fomites, Flies, Feces, Food & Fluids
Pathophysiology
Oral ingestion Bloodstream Reticuloendothelial system (lymph node, spleen, liver) Bloodstream Gallbladder Peyers patches of SI necrosis and ulceration
Typhoid Fever
Clinical Manifestations: Incubation Period: 1-2 weeks 1. Prodromal 1st week: Step ladder fever 40-41 deg, headache, abdominal pain, GI manifestations 3 cardinal signs of pyrexial stage: 1.ROSE SPOTS ( irregular rashes found on the chest, abdomen, back 2. Remittent fever ( ladder like) 3. Spleenomegaly
2. Fastidial = 2nd week ( Typhoid) a. High fever, typhoid psychosis w/ hallucination, confusion, delirium
1st week step ladder fever (BLOOD) 2nd week rose spot and fastidial typhoid psychosis (URINE & STOOL) 3rd week (complications) intestinal bleeding, perforation, peritonitis, encephalitis, 4th week (lysis) decreasing S/SX 5th week (convalescence)
Dx: Blood culture (typhi dot) 1st week Stool and urine culture 2nd week Widal test Mgmt: Chloramphenicol, Amoxicillin, Sulfonamides, Ciprofloxacin, Ceftriaxone ** Observe standard precaution until 3 negative stool culture**
Nursing Interventions
Environmental Sanitation Food handlers sanitation permit Supportive therapy Assessment of complications (occuring on the 2nd to 3rd week of infection ) - typhoid psychosis, typhoid meningitis - typhoid ileitis
Schistosomias/Snail Fever/Bilharziasis/Katayama
Causative agent : Oriental Blood Fluke Schistosoma japonicum (affects intestinal tract) S. hematobium ( affects urinary tract) S. mansoni ( affects intestinal tract)
IP: 2 months Source: feces of infected persons
serve as HOSTS
Ulceration in the mucosa Eggs able to escape in the lumen Of intestine, excreted in the feces
Some eggs carried by portal Circulation, filtered in the Liver , formed granulomas
Granulomas are resolved & replaced by fibrous tissues Scar formation occur Diseases progresses Liver enlarges due To increasing fibrosis Blood flow interrupted Result to portal hypertension
Schistosomias/Snail Fever/Bilharziasis/Katayama
Causative agent : Oriental Blood Fluke Schistosoma japonicum (affects intestinal tract) S. hematobium ( affects urinary tract) S. mansoni ( affects intestinal tract)
IP: 2 months Cycle: Egg - larvae (miracidium) - intermediary host (oncomelania quadrasi/tiny amphibious snail) cercaria ( infective stage)
Schistosomias/Snail Fever
MOT: penetration of cercaria to the skin >parasites live in the blood vessels of intestines>cercaria migrates to the liver for maturation> gets out of the liver & goes against blood flow> obstruction of hepatic portal vessels> inc pressure>portal hpn>leads to esophageal & gastric varices, ascites & hepatomegaly
Assessment :
Swimmers
itch or cercarial dermattitis itching within 24hrs after penetration of the skin by cercaria last 2-3 days Migratory phase : sensitized individual develop systemic reaction of FEVER, CHILLS , SWEATING , DIARRHEA , COUGH and EOSINOPHILIA Acute Phase : (+) fever , generalized lympagenopathy, hepatomegaly and splenomegaly ( KATAYAMA FEVER) 2-3 weeks after initial infection and last for 1-2 months
Diagnostics:
Fecalysis
or direct stool exam Kato katz technique Liver and rectal biopsy ELISA ( enzyme link Immunosorbent Assay) COPT ( circum-oval precipitin test) confirmatory diagnostic test
Wear knee rubber boots Avoid washing clothes or bathing in streams Use potable water supply Proper & sanitary disposal of human feces Snail control may be undertaken by chemicals ( Niclosemide)- Molluscides Annual stool exam in endemic places Educate people about transmission Proper maintenance of Latrine
Viral hepatitis
VIRAL HEPATITIS
A diffuse inflammation of the cells of the liver that produces liver enlargement and jaundice
Hepatitis
A (HAV) fecal-oral route Hepatitis B ( HBV) contact with body fluids Hepatitis C (HCV) percutaneous exposure to blood ( non A non B) Hepatitis D (HDV)- contact with body fluids Hepatitis E (HEV) water , fecal-oral route
VIRAL HEPATITIS
HAV
IP MOT
15-50d
HBV
45-180d
HCV
14-182d
HDV
14-70d
HEV
15-64d
Fecal oral
Same w/ B
Fecal oral
Failure of the bile to reach intestine in normal amount Obstructed jaundice s/sx: dark urine, pale feces, itchness
Assessment : s/sx
Prodromal
VIRAL HEPATITIS
/ Preicteric S symptoms of URTI W weight loss A anorexia , chills , fever R right upper quadrant pain M malaise Icteric J jaundice A acholic tool B bile colored urine ( tea colored)
Laboratory :
Liver function test SGPT/SGOT Specific : the presence of IgM antibody Hepatitis A IgM HAV Hepatitis B HbsAg acute or chronic infected Anti-HBs resolved or immunity HbeAg infected risk of transmitting Anti-HBe lower risk of transmitting Anti-HBc acute resolved or chronic HBV infection IgM anti-HBc acute with recent HBV infection window phase
Enteric fever
VIRAL HEPATITIS
Analysis
Knowledge deficit related to unfamiliarity with the disease course and treatment Activity intolerance related to decreased metabolism of nutrient / increased basal metabolic rate caused by viral infection High risk for Diversional activity deficit secondary to isolation / lack of energy High risk for altered body nutrition : less than body requirement secondary to anorexia
VIRAL HEPATITIS
Treatment
No specific treatment Bed rest essential Diet : high carbohydrate , low fat , low protein Vitamin supplement ( B complex)
VIRAL HEPATITIS
Nursing Mgt
Isolation of patient ( enteric isolation) Standard precaution Patient should be encouraged to rest during acute or symptomatic phase Improved nutritional status Utilize appropriate measures to minimize spread of the disease
VIRAL HEPATITIS
Nursing Mgt
Observe patient for Melena and check stool for the presence of blood Provide optimum i and oral care Increase in ability to carry out activities
Encourage the patient to limit activity when fatigued Assist the client in planning period of rest and activity Encourage gradual resumption of activities and mild exercise during recovery
PREVENTION AND CONTROL Handwashing every after use of toilet Travelers should avoid water and ice if unsure of their purity Educate on the mode of transmission of the disease.
ERUPTIVE FEVER
MEASLES
Extremely contagious Breastfed babies of mothers have 3 months immunity for measles The most common complication is otitis media The most serious complications are pneumonia and encephalitis
RNA, Paramyxoviridae Measles virus is rapidly inactivated by heat, UV light, & extreme degrees of acidity & alkalinity Active immunity (MMR and Measles vaccine) Passive immunity (Measles immune globulin) Lifetime Immunity IP: 8-12 days MOT: Direct ( droplets, airborne); Indirect ( fomites) *Contagious 1-2 days before rash and 4 days after the appearance of rash
Sources of Infection:
Patients blood Secretions from the eyes, nose & throat Diagnostics: Nose & throat swab Urinalysis Blood exams ( CBC, leukopenia, leukocytosis)
Rashes: maculopapaular,
cephalocaudal (hairline and behind the ears to trunk and limbs), confluent, desquamation, pruritus)
Clinical manifestations:
1. Pre-eruptive stage: (2-4 days) - malaise, cough, conjunctivitis, , fever, kopliks spots ( PATHOGNOMONIC SIGN) (1-2 mm blue white spots on red background along 2nd molars), stimsons ( puffiness of eyelid) photophobia 2. Eruptive stage: Rash is usually seen late on the 4th day Maculo-papular rash 3. Stage of convalescence: Rashes fade away, desquamation begins,fever subsides Cx: pneumonia, meningitis,
MEASLES
Fever
persist means (+) complication Bronchopneumonia- most common Otitis media, reactivation of previous TB Bronchitis, laryngitis, exacerbation malnutrition Encephalitis
MEASLES
Diagnostic procedure
Physical examination Nose and throat swab Urinalysis CBC ( leukopenia & leukocytosis) Complement fixation or hemogglutinin test
Eruptive fever
1. 2. 3. 4. 5.
6.
7.
MANAGEMENT Supportive Hydration Proper nutrition Vitamin A Antibiotics if w/ secondary bacterial infection Vaccine- measles vaccine @ 9 mos and MMR @ 15 mos Anti viral drugs ( Isoprenosine)
Nursing Care
Isolation of the patient if necessary TSB for fever Skin care is of utmost importance. The pt. should have a daily cleansing bed bath. Oral & nasal hygiene is a very important aspect of nursing care of patients with measles Restrict to quiet environment Dim light if photophobia is present; care of the eyes is necessary Administer antipyretic Use cool mist vaporizer for cough
= contagious viral disease characterized by fever, URTI, arthralgia, DIFFUSED fine red maculopapular rash) CA - RNA, rubella virus ( Togaviridae) Immunity: Active natural ( permanent or lifetime) Active immunity - rubella vaccine and MMR Passive immunity - gammaglobulin Period of communicability contagious 7 days before & 7 days after appearance of rash & probably during the catarrhal stage
Rashes: Maculopapular, Diffuse/not confluent, No desquamation, spreads from the face downwards
Clinical Manifestations: > FORSCHEIMERS SPOTS (petecchial lesion on buccal cavity or soft palate) > oval, rose red papule about the size of pin head > cervical lymphadenopathy, > low grade fever Dx: clinical CX: rare; pneumonia, meningoencephalitis CX to pregnant women: 1st tri-congenital anomalies ( microcephaly, heart defects, cataracts, deafness 2nd tri-abortion or bleeding 3rd tri-pre mature delivery
Nursing Considerations:
MMR immunization Use of immunoglobulins ( IGs)- ppost exposure prophylaxis 72 hrs after exxposure Prevention of congenital measles Avoid exposure
S/sx: Spiking fever w/c subsides 2-3 days, Face and trunk rashes appear after fever subsides, Mild pharyngitis and lymph node enlargement Mgmt: symptomatic
Most highly contagious childhood disease Affects adults more severely than children Virus may become dormant
Acute & highly contagious disease of viral etiology Childhood disease & adolescents (adults more severe) Not common in infancy Locally called Bulutong Human beings are the only source of infection CA = Varicella Zoster virus, Herpes virus IP 10-21 days MOT: droplet spread > nose & throat secretions > Vesicles ( contagious in early stage of eruption > Airborne
Prodromal period: headache , vomiting, fever Papulovesicular rashes appear on trunk spreading to face and extremties ( centrifugal)
Macules
papules vesicles with clear fluid inside crusting and scar formation
The
disease is communicable until the last crust disappear ( D1 before D6 after appearance of rashes)
Period of Communicability 5 days before rashes & 5 days after rashes crusting - dry
Rashes: Maculopapulovesicular (covered areas), Centrifugal rash distribution, starts on face and trunk and spreads to entire body
Dormant: remain at the dorsal root ganglion and may recur as shingles (VZV)
If it feels itchy, give oral antihistamine or local antihistamine Avoid rupture of lesions Cut nails short Pay attention to nasopharyngeal secretions/ discharges Disinfection of linen ( sunlight or boiling) Prophylactic antibiotics
Tepid water and wet compresses for pruritus Soothing Baths, cool baths
Treatment:
a. oral acyclovir b. Tepid water and wet compresses for pruritus c. Potassium Permanganate (ABO) a. Astringent effect b. Bactericidal effect c. Oxidizing effect (deodorize the rash)
Exclusion from school for 1 week after eruption appears An attack gives lifetime immunity. Second attack is rare Immunoglobulins can be given ( 12 mos) Drug of choice: Acyclovir ( Zovirax ) topical cream applied to crusts
Preventive measures
DNA, Pox virus Last case 1977 spreads from man-toman only Active: Vaccinia pox virus
SMALL POX
Complications:
Scarring Pneumonia Blepharitis Corneal ulceration
Mortality rate : 30% Diagnostic : clinical evaluation Treatment : analgesic ( pain) antibiotic for secondary infection
SMALL POX
Nursing mgt
Strict respiratory and contact isolation Supportive Adequate hydration Mandatory reporting
PREVENTION
Pre-exposure vaccination Strict isolation of identified cases
Respiratory Diseases
Meningococcemia
CA : Neisseria meningitides ( bacteria) gram ()diplococci May also be caused by H. Influenzae and S. Pneumoniae MOT: Droplets (urti) to blood stream to CNS
S/sx: 1. Meningococcemia usually starts as nasopharyngitis, followed by sudden onset of spiking fever, chills, arthralgia. Bacteria is carried by circulation & when it reaches the meninges of the brain, BLEEDING occurs into the medulla which extends to the cortex & petechial, purpuric or ecchymotic hemorrhage is scattered in the entire body surface appear. 2. Fulminant Meningococcemia (Waterhouse Friedrichsen) septic shock; hypotension, tachycardia, enlarging petecchial rash, adrenal insufficiency
Clinical Manifestation
sudden onset of high grade fever, rash and rapid deterioration of clinical condition within 24 hours
Treatment:
antimicrobial Benzyl Penicillin 250-400000 u/kg/day ( drug of choice) Chloramphenicol 100mg/kg/day Symptomatic and supportive fever seizures hydration respiratory function Chemoprophylaxis Rifampicin 300-600mg q 12hrs x 4 doses Ofloxacin 400mg single dose Ceftriaxone 125-250mg IM single dose ( Ciprobay)
Nursing Intervention 1. To prevent the occurrence of further complications -maintain strict surgical aseptic technique when doing dressings or lumbar puncture in order to prevent the spread of microorganism -administer O2 inhalation to prevent respiratory distress and to maintain a clear open airway -TSB for fever to prevent convulsions -observe signs and symptoms of increase intracranial pressure -change positions at least every 2 hours to prevent pressure sore -protect the eyes from bright lights and noise
2. Maintain normal amount of fluid and electrolyte balance 3. Prevent spread of the disease, prophylaxis for close contacts ( Rifampicin ) 4. Ensure the patients full comfort, prevent stress provoking factors that may retard convalescence and to prevent from injury 5. Prevent the spread of infection, microorganisms and contamination some precautions should be carried out
6. Maintain personal hygiene and cleanliness and avoid microorganisms to harbor in the patients body 7. Maintain proper elimination of waste product of metabolism 8. Nutritional intake
Diphtheria
IP: 2-5 days Period of Communicability: 2-4 wks if untreated, 1-2 days if treated Active (DPT) and Passive Immunization (Diphtheria antitoxin) Source: Discharges of the nose, pharynx, eyes, or lesion of other parts of the body infected More severe in unimmunized and partially immunized
1. Nasal invades nose by extension from pharynx 2. Tonsillar low fatality rate 3. NasoPharygeal- more severe type - sore throat causing dysphagia - Pseudomembrane in uvula, tonsils, soft palate gray exudate - Bullneck inflammation of cervical LN; neck tissues are edematous - increasing hoarseness until aphonia - wheezing on expiration - dyspnea
4. Cutaneous diphtheria affect mucous membrane & any break on the skin
S/sx: sore throat, fever, Bull-neck appearance( CHARACTERISTIC SIGN) ,Pseudomembrane-( PATHOGNOMONIC SIGN) gray exudate, foul breath, massive swelling of tonsils and uvula, thick speech, cervical lymphadenopathy, swelling of submandibular and anterior neck), obstruction of respiratory tract
Dx: 1.Schick test susceptibility to diphtheria toxin 2. Moloney - sensitivity to diphtheria toxoid 3. Throat swab (K tellurite and Loefflers coagulated blood serum
Treatment
Neutralize the toxins antidiptheria serum Kill the microorganism penicillin, erythromycin, rifampicin, clindamycin Considered cured after 3 negative throat cultures Prevent respiratory obstruction tracheostomy, intubation CBR up to 2 weeks to prevent myocarditis Strict isolation
Nursing intervention
Maintenance of adequate fluid and electrolytes Bed rest for at least 2 weeks
Avoid exertion
Ice collar must be applied to the neck Nose and throat must be taken care of Administer antibiotics as prescribed
Complications
Myocarditis most common ( caused by diphtheria toxin on the heart muscles) Polyneuritis paralysis of the soft palate, paralysis of the ciliary muscle of the eye, pharyns, larynx, or extremities Airway obstruction can lead to death through asphyxiation
S/sx:
1. 2. 3.
Catarrhal stage (1-2 wks; highly contagious) sneezing, runny nose,tearing lacrimation, mild cough, low grade fever Paroxysmal stage (2-4 wks) - Clusters of cough that ends with a whoop, vomiting, exhaustion Convalescent stage (2-3 wks) less frequent cough
Dx: WHO - >21 days cough + close contact w/ pertussis px + (+) culture OR rise in Ab to FHA or pertussis toxin * throat culture w/ Bordet gengou agar
Cx: bronchopneumonia, pneumonia Management: liquefy thick secretions with Ferrous iodide CBR Warm fresh air is better than cold air w/c induces vomiting ( NO AIRCON) Hydration and nutrition Vit C to inc body resistance Oxygen ( 1-2L/min)- to lessen the occurrence of paroxysm Erythromycin or Ampicillin Isolation = 4 wks after coughing begins & continued for 7 days after the onset of antiobiotic therapy
CA: Mycobacterium tuberculosis ( bacteria), acid fast bacilli The organism multiplies slowly & is characterized as acid fast aerobic organism which can be killed by heat, sunshine, drying & ultraviolet light. Sputum of persons with TB is the most common source of the organism spread through droplet ( airborne) Potts disease thoracolumbar Milliary TB kidney, liver, lungs
Is a chronic, or subacute or acute respiratory disease commonly affecting the lungs characterized by formation of tubercles in the tissues which tend to undergo caseation, necrosis and calcification. IP: 2 10 weeks Mode of Transmission: Direct: droplet ( sneezing, coughing) Indirect: continuous exposure to infected persons within the family Source of Infection:sputum, blood from hemoptysis, nasal discharges and saliva
-
Classification :
Minimal slight lesion Moderately advanced one or both lung may be involved Far advanced- more extensive
Clinical classification:
1. inactive TB
Symptoms absent Sputum negative CXR no evidence of cavity
2. Active
Tuberculin test positive CXR progressive (+) of symptoms Sputum (+)
Clinical manifestation:
Afternoon rise of temperature for 1 mo. or more Night sweating Body malaise, weight loss Cough, dry to productive Dyspnea, horseness of voice Hemoptysis pathognomonic Occasional chest pain (+) sputum for AFB
PD 996 Compulsory Immunization below 8 years ( 0 -7 yrs) Proclamation # 6 WHO Universal Child Immunization
Etiologic Factors that contribute heavily to the high Incidence & high mortality rate of TB: Poverty / Overcrowded homes Protein undernutrition Deficiencies in Vit A,D,C Children below 5 years old prone to infection due to inadequate levels of immunity
Pathophysiology
Inhalation Local infiltration of neutrophils and macrophage
If reactivated, Secondary TB
DX
1. Case Finding:
A. Sputum Microscopy ( cheapest & confirmatory ) Results take about 3 weeks to confirm Sputum sample shld be taken 1st thing in the morning upon arising 3 specimens: 1st on the spot = HC 2nd- upon arising = Home 3rd on the spot = HC
2. Sputum Culture & Sensitivity 3. Chest X-ray cavitary lesion 4. Tuberculin Test
1. PPD Purified Protein Derivative 2. Mantoux Test- (more reliable) = ID injection of tuberculin extract into the inner aspect of forearm to detect infection/exposure to CA. Localized reaction- detected in 48 to 72 hours (+) induration of 10 mm or above
Tuberculin test. Erythema and induration at site of intradermal injection of 5 tuberculin units in a child with primary tuberculosis. This is an unusually severe reaction. Mantoux method.
Classification of PTB
0 = No exposure; No infection 1 = (+) exposure but not infected = INH for 1 mo especially below 5yo 2 = (+) with infection but w/o disease (+) skin test; No S/S; CXR(-) -INH 1 yr ( -) sputum exam 3 = infected & w/ the disease = anti TB drug Tx
CATEGORIES OF TB
category I (new PTB) - (+) sputum(+) chest xray category II (PTB relapse not less than 6 mos)
category III (active PTB case) - (-) sputum chest xray, regression of infiltrates Category 1V partially treated; poor compliance to DOTS Category V PTB suspect ( (+) skin test; (+) family member with PTB
Management: short course 6-9 months long course 9-12 months DOTS- directly observe treatment short course
* 2 wks after medications non communicable 3 successive (-) sputum - non communicable rifampicin or INH- prophylactic
TREATMENT:
CATEGORY 1 - NEW PTB, (+) SPUTUM GIVE RIPE 2 MONTHS, MAINTENANCE OF RI 4 MONTHS
CATEGORY 2 - PREVIOUSLY TREATED WITH RELAPSES GIVE RIPES 1ST 2 MONTHS, REPS 1 MONTH, MAINTENANCE RIE 5 MONTHS
CATEGORY 3 - NEW PTB (-) SPUTUM FOR 3X GIVE RIP 2 MONTHS, MAINTENACE RI 2 MONTHS
2. Isoniazid (INH) = ( Bacteriostatic) inhibits ( Bactericidal ) kills Used prophylactically to patients (+) of PPD SE = Rashes (give anti-histamine); Peripheral neuritis ( Give Vit B6- Pyridoxine)50 mg; Jaundice; Psychosis
3. Pyrazinamide ( PZA) SE = Hyperuricemia ( inc uric acid) Mx: Inc fluid intake 4. Ethambutol = 15-20mg/day SE = Optic neuritis ( dec visual acuity) Give Vit. B6(Pyrdoxine) 5. Streptomycin SE = Ototoxicity, 8th cranial nerve damage
MDT side effects r-orange urine i-neuritis and hepatitis p-hyperuricemia e-impairment of vision s-8th cranial nerve damage
2.
3. 4.
5. 6. 7. 8. 9. 10.
MAINTAIN REPIRATORY ISOLATION Administer medicine as ordered Always check sputum for blood or purulent expectoration Encourage questions and conversation so that the patient can air his or her feelings Teach or educate the patient all about PTB Encourage patient to stop smoking Teach how to dispose secretion properly Advised to have plenty of rest and eat balanced diet Be alert of drug reaction Emphasize the importance of follow-up
-Acute contagious VIRAL disease. Characteristic feature is swelling of one or both of the parotid glands RNA, Mumps virus ; paromyxovirus of the Varicella family( found in the saliva) Mumps vaccine - > 1yo MMR 15 mos Lifetime Immunity IP: 14-25 days, usually 18 days Incidence: 5-15 y/o, cold weather, common in men. Adults less likely to be attacked ( If so, causes sterility) MOT: droplet, fomites, saliva
S/sx: Pain at the angle of the jaw (Unilateral or bilateral) PATHOGNOMONIC SIGN parotitis, Orchitis - sterility if bilateral, Period of communicability: 6 days before swelling ; until 9 days after swelling subsides ( 7th 9th day) ** highest communicability 48 hrs after onset of swelling Dx: serologic testing, ELISA Mgmt: supportive Supporter for orchitis Analgesics Antipyretic, cold compress, steroids
Diet : soft. Dont give sour foods Promotive: Proper disposal of nasal & throat secretions Bed rest Preventive: MMR vaccine ( 15 mos.) = LIFETIME IMMUNITY
Diarrheal
Diseases
Cholera / El Tor
Causative agent: Vibrio coma (inaba, ogawa, hikojima), vibrio cholerae, vibrio el tor; gram (-) Curved rod or coma shaped organism; motile Habitat: small intestine Can survive longer in refrigerated foods IP: few hours to 5 days MOT: oral fecal route ( by contaminated food, water, shellfish)
S/sx: Severe vomiting, abdominal cramps, massive diarrhea of watery voluminous whitish grayish greenish slightly mucoid stools (Rice watery stool with flecks of mucus & fishy odor), s/sx of severe dehydration ie Washerwomans hands, sunken eyeball & fontannel, thirst, poor skin turgor Period of communicability: 1st day 10th day ( as long as CA is seen in feces) Dx: stool culture (+) vibrio cholerae Mgmt: IV fluids, Tetracycline, Doxycycline, Erythromycin, Quinolones, Furazolidone and Sulfonamides (children)
Nursing Mx:
Pathophysiology
S/sx: fever,colicky abdominal pain, diarrhea is watery to bloody with pus, tenesmus ( pain on defecation) Dx: stool culture Mgmt: Oresol, Ampicillin, TrimethoprimSulfamethoxazole, Chloramphenicol, Tetracycline, Ciprofloxacin
Nursing Mx:
Replacement of F & E Good environmental sanitation Sanitary disposal of human feces Clean processing, preparation, serving of food Fly control
Source : contaminated food, drinks ;meat and poultry product. MOT : fecal oral-route Period of communicability : throughout duration of fecal excretion IP : 6-72H ( < 24H) S/SX : abrupt onset nausea, vomiting, abdominal cramps, chills, LBM with bloody mucoid stool occassionally
Physical findings: hyperactive peristalsis, abdominal tenderness and signs of dehydration. Diagnosis:
Treatment
Correction of fluid and electrolytes Dietary Resistant to antibiotics likes : ampicllin, chloramphenicol and cotrimoxazole
Botulism
Fatal form of food poisoning caused by an endotoxin CA = Clostridium Botulinum MOT = Food borne or contaminated wound IP = 12-36 hrs after eating improperly canned foods
1.
2. 3.
4.
5.
S/SX Severe intoxication Visual difficulty, Dysphagia, dry mouth Descending, symmetrical flaccid paralysis ( weak, soft) Vomiting, constipation, Diarrhea Double vision, difficulty focusing eyes
Dx Culture of stool & stomach contents Serum positive of Botulinum toxins Nursing & Medical Management: 1. IV & IM trivalent Botulinum antitoxin 2. IV fluids & Electrolytes 3. Intensive care to manage respiratory failure 4. No questionable canned food should be tested
Intestinal Parasitism
INTESTINAL PARASITISM
are parasites that populate the gastro-intestinal tract. MOT : they are often spread by poor hygiene related to feces
A. Helminths
Tapeworms, pinworms, and roundworms are among the most common helminths
B. Protozoa.
INTESTINAL PARASITISM
Diarrhea Nausea or vomiting Gas or bloating Dysentery (loose stools containing blood and mucus) Rash or itching around the rectum or vulva Stomach pain or tenderness Feeling tired Weight loss Passing a worm in your stool Anemia
Fecal testing (stool exam) can identify both helminths and protozoa..
The "Scotch tape" test identifies pinworm by touching tape to the anus. Then the tape is examine under a microscope for eggs
CA: Ascaris Lumbricoides IP: weeks to months MOT: transmitted through contaminated fingers into the mouth; ingestion of food and drinks contaminated by embryonated eggs Affects 4-12 years old Dx: stool for ova Mgmt: Mebendazole,/ Albendazole/ Pyrantel Pamoate
Ascariasis (Roundworm)
MOT: ingestion of food contaminated by ascaris eggs larvae in large intestine penetrate wall lung where larvae grow and coughed up intestine larvae mature and passed out in feces
Nursing Intervention:
Isolation is not needed Preventive measures in each home and in the community should be enforced Wash hands before handling food Wash all fruits and vegetable thoroughly Availability of toilet facilities must be ensured Importance of personal hygiene should be explained Proper waste disposal.
Prevention:
Improved sanitation and hygienic practices Improved nutrition Deworming may be advised
Complications
Migration of the worm to different parts of the body Ex. Ears, mouth,nose Loefflers Pneumonia
Tapeworm (Flatworms)
CA: Taenia Saginata (cattle), Taenia Solium (pigs) MOT: fecal oral route (ingestion of uncooked, infected meat ) IP: 2-3 mos - years Dx: Stool Exam Mgmt: Praziquantel, Niclosamide ISOLATION OF HOSPITALIZED PATIENTS. STANDARS PRECAUTIONS RECOMMENDED
Pinworm
Enterobius Vermicularis MOT: fecal oral route S/sx: Itchiness at the anal area d/t eggs of the agent Dx: tape test at night time (agents release their eggs during night time) Mgmt: Pyrantel Pamoate, Mebendazole
Nursing Intervention
Promote hygiene Environmental Sanitation Proper waste and sewage disposal Antihelmintic medications repeated after 2 weeks (entire family)
CA: Necator Americanus, Ancylostoma Duodenale IP - few weeks to months to years S/sx: Ground itch or dew itch at site of entry of filariform larvae involving the feet/legs, abdl cramps, diarrhea, abdl distention, anemia, perforation to peritonitis to septicemia ** Isolation is not necessary **
Hookworm (Roundworm)
Dx: microscopic exam (stool exam) Mgmt: Pyrantel Pamoate and Mebendazole dont give drug without (+) stool exam members of the family must be examined and treated also Nsg. Intervention: 1. Proper disposal of excreta 2. Avoid walking or playing barefooted 3. Periodic deworming of school age group
Protozoal infection of human beings initially involving the colon, but may spread to soft tissues, most commonly to the liver or lungs. CA: Entamoeba Hystolitica, protozoa
Prevalent in unsanitary areas Common in warm climate Acquired by swallowing Cyst survives a few days after outside of the body Cyst passes to the large intestine & hatch into TROPHOZOITES. It passes into the mesenteric veins, to the portal vein, to the liver thereby forming AMOEBIC LIVER ABSCESS.
b. This is considered as the infective stage in the life cycle of E. histolytica Pathology When the cyst is swallowed, it passes through the stomach unharmed and shows no activity while in an acidic environment. When it reaches the alkaline medium of the intestine, the metacyst begins to move within the cyst wall, which rapidly weakens and tears. The quadrinucleate amoeba emerges and divides into amebulas that are swept down into the cecum. This is the first opportunity of the organism to colonize, and its success depends on one or more metacystic trophozoites making contact with the mucosa.
Mature cyst in the large intestines leaves the host in great numbers (the host remains asymptomatic). The cyst can remain viable and infective in moist and cool environment for at least 12 days, and in water for 30 days. The cysts are resistant to levels of chlorine normally used for water purification. They are rapidly killed by desiccation, and temperatures below 5 and above 40 degrees.
MOT: Ingestion of cysts from fecally contaminated sources (Oral fecal route) oral and anal sexual practices Extraintestinal amoebiasis- genitalia, spleen, liver, anal, lungs and meninges
lifecycle
s/sx: Blood streaked, watery mucoid diarrhea, abdominal cramps Dx: microscopic stool exam - trophozoites Pd of Communicability: the microorganism is communicable for the entire duration of the illness Mgmt: Tetracycline 250 mg every 6 hours Ampicillin, Quinolones, sulfadiazine Metronidazole (Flagyl) 800 mg TID x 5 days Strptomycin SO4, Chloramphenicol F&E balance
Nsg. Mx
Observe isolation & enteric precaution Provide health education & instruct patient to:
Boil water for drinking or use purified water Avoid washing food from open drum or pail Cover leftover food Wash hands after defecation or before eating Avoid ground vegetables ( lettuce, carrots, etc)
Prevention:
Health education Sanitary disposal of feces Protect, chlorinate & purify drinking water Observe scrupulous cleanliness in food preparation & food handling Detection & tx of carriers Fly control ( they can serve as vectors)
CNS Infections
Is the inflammation of the meninges of the brain and spinal cord as a result of viral or bacterial infection. IP : varies from 1-10 days MOT : respiratory droplet
direct invasion through otitis media may result after skull fructure
Clinical manifestations
headache irritability fever neck stiffness pathologic reflexes: kernigs, Babinski, Brudzinski
Diagnostics:
Lumbar puncture Gram staining Smear and blood culture Urine culture
Supportive/Symptomatic:
MOT: The virus is transmitted from person to person by: 1. indirectly through contaminated articles and flies, contaminated water, food & utensils 2. Intimate contact w/ infected person 3. Direct contact thru nasopharyngeal secretions Dx: 1.Pandys test culture of CSF (increased CHON) 2. Stool culture throughout the disease 3. Isolation of the virus from throat washings or swab early in the disease
IP: 7-21 days Period of Communicability: first three days after onset of S/SX until three months of illness The disease is most contagious during the first few days of active disease, and possibly from 3-4 days before that
Types of Polio:
1. Abortive or inapparent type does not invade the CNS ( fever, malaise, sore throat, headache, N&V) pt. usually recovers within 72 hours 2. Non-paralytic all the above signs; marked w/ meningeal irritation; pain in the neck, back, arms legs & abdomen; inability to place the head in between the knees; (+) pandys test; more severe than abortive type (
3. Paralytic polio s/sx listed above are present; flaccid asymmetrical ascending paralysis (Landrys sign), (+) Hoynes sign (head drop), Pokers sign (opisthotonus), (+) Kernig and Brudzinski sign 4. Bulbar ( Brain stem) develops rapidly & is the more serious type; motor neuron in the brainstem is attacked & affects the medulla. It weakens the muscles supplied by the cranial nerves especially the 9th ( glossopharyngeal) & 10th ( vagus); facial, pharyngeal & ocular muscles are paralyzed; respiratory failure & cardiac irregularities
Predisposing causes
Age about 60% of patients are under 10 yrs of age Sex males are more prone to the disease than females with a ratio of 3:2 Heredity poliomyelitis is not hereditary Environment & hygienic condition. The rich are more often spared than the poor. Excessive work, strain, marked overexertion are also factors causing the disease.
Pathology
The organism enters the body through the alimentary tract, multiplies in the oropharynx & lower intestinal tract. Then the organisms are spread to the regional lymph nodes & the blood There seems to be subsequent congestion, edema & necrosis in the area
Complications
Respiratory failure Circulatory collapse Electrolyte imbalance Bacterial infection Urinary problems r/t retention or paralysis of the urinary bladder
MGMT: Analgesics for pain. Morphine is contraindicated because of the danger of additional respiratory suppression. CBR Moist heat application may reduce spasm & pain Paralytic polio requires rehabilitation using physical therapy , braces, corrective shoes & in some cases, orthopedic surgery Prevention: Active OPV (Sabin) and IPV (Salk)
Nursing Management:
Carry out enteric isolation Observe the patient carefully for paralysis & other neurologic damage Perform neurologic assessment 1x a day Check BP regularly especially in bulbar polio Maintain good personal hygiene, particularly oral care & skin care Provide emotional support both to patient & family Dispose excreta & vomitus properly Apply hot packs to affected limb to relieve pain & muscle shortening
Tetanus/Lockjaw/Trismus
CA: Clostridium tetani (gram (+), spore forming, anaerobic ( survives w/o air) non-motile, vegetative( ability to grow) Produces potent exotoxin Tetanus spores are introduced into the wound contaminated with soil IP: 4-21 days Tetanus neonatorum - umbilical cord
Pathophysiology
Clostridium tetani in puncture wound Release of Neurotoxin (Tetanospasmin) Hemolysin ( tetanolysin attack PNS and CNS GABA and Glycine inhibited
Tetanic spasm
Clinical manifestations
Difficulty of opening the mouth (trismus or lockjaw) Risus sardonicus ( sneering grin) ngiting aso Dysphagia Generalized muscle rigidity Opisthotonus ( severe arching of the back) Localized or generalized muscle spasm Respiratory paralysis to death
S/Sx:
Criteria
Stage I
Trismus
mild
moderate
Severe
Muscle rigidity
mild
Pronounced
Severe, boardlike
Spasm
absent
Mild, short
Frequent, prolonged
Dyspnea, cyanosis
absent
absent
Present
Dx: history, leukocytosis, serum antitoxin levels Mgmt: Anticonvulsant, muscle relaxants, antibiotics, wound cleansing and debridement Active-DPT and tetanus toxoid Passive-TIG and TAT, placental immunity
Tetanus
Treatment: 1. Specific : -within 72 hours after punctured wound received ATS,TAT or TIG espicially if no previous immunization - Pen G to control infection - muscle relaxant to decrease muscle rigidity. 2. Non-specific - oxygen inhalation
Treatment:
anti-toxin Tetanus Anti-Toxin (TAT) Adult,children,infant Neonatal Tetanus TIG Neonates Adult, infant, children 40,000 IU IM,1/2 IV 20000 IU, 1/2IM, IV 1000 IU, IV drip or IM 3000 IU, IV drip or IM
DPT- 0.5 ml IM 1 - 1 months old 2 - after 4 weeks 3 - after 4 weeks 1st booster 18 mos 2nd booster 4-6 yo subsequent booster every 10 yrs thereafter TT 0.5 ml IM TT1 6 months within preg TT2 one month after TT1 TT3 to TT5 every succeeding preg or every year
Antimicrobial Therapy Penicillin !-3 mil units q 4hours Pedia 500000 2mil units q 4 hrs Neonatal 200000 units IVP q 12hrs or q8hrs
Rabies
CA: Genus
acute viral encephalomyelitis incubation period is 4 days up to 19 years risk of developing rabies, face bite 60%, upper extremities 15-40%, lower extremities 10% 100% fatal
Pathophysiology
Bite/wound Local wound replication
CNS
ANS
encephalitis
Salivary glands, adrenal medulla, kidney, lungs, skeletal muscles, skin, heart
Rabies Virus The rabies virus is usually transmitted to humans by a bite from an infected dog, but the bite of any animal (wild or domestic) is suspect in an area where rabies is present. Symptoms of the disease appear after an incubation period of ten days to one year and include fever, breathing difficulties, and muscle spasms in the throat that make drinking painful. Death almost invariably occurs within three days to three weeks of the onset of symptoms. For this reason, the emphasis of treatment is on prevention. In the United States, veterinarians recommend regular vaccination of domestic dogs.
Clinical Manifestation
4 STAGES
1. prodrome - fever, headache, paresthesia, 2. encephalitic excessive motor activity, hypersensitivity to bright light, loud noise, hypersalivation, dilated pupils 3. brainstem dysfunction dysphagia, hydrophobia, apnea 4. death
Dx: history virus isolation from saliva and CSF serial serum Ab sample Staining of brain tissue (dog) - Negri bodies
Postexposure prophylaxis
Category I Licking of intact skin Observe the dog for 14 days
1.Active
Category III Abrasion, laceration on upper extremities, head and neck Dog is killed, lost, died
1.Active 2.Passive
Category of bites
I intact skin (lick or scratch) II mucosal, non bleeding wounds, abrasions III bleeding bites and above neck, stray dogs, laceration, multiple bites
Mgmt: - wound cleansing - tetanus prophylaxis - Observe and quarantine dog for maniacal s/sx - Active- antirabies vaccine (human diploid cell vaccine) - 7-10 days to induce an active immune response, with immunity x 2 years - Passive human rabies immunoglobulin
Antirabies vaccine 1 ml IM day 0, 3, 7, 14, 28 OR 0.1 ml ID day 0 (8 sites), 7 (4 sites), 28, 91 (1 site) OR 0.1 ml ID day 0, 3, 7 (2 sites), 30, 90 (1 site)
Rabies immunoglobulin (HRIG/equine antiserum) 20/40 units/kg IM single shot wound 40%, deltoid 60%
Infection control Patient is isolated to prevent exposure of hospital personnel, watchers and visitors PPE Preventive Measures Education Post-exposure and Pre-exposure Prophylaxis
SNAKEBITE
Neurotoxic
Cobra
Myotoxic
None
Sea snake
Vasculotoxic
Rapid swelling
Bleeding abnormalities
Vipers
Management
Lie the victim flat ice compress and constrictive materials are contraindicated Transport the patient to the nearest hospital Antivenim administration in patients with signs of envenomation It is never too late to give anti-venim
Antivenim is given thru intravenous infusion, which is the safest and most effective route. 2-5 ampules plus D5W to run over 1-2 hours every 2 hours Antimicrobial therapy sulbactam/Ampicillin or co-amoxiclav Substitute Prostigmine IVinfusion, 50-100ug/kg/dose q 8hrs Atropine
Leprosy/Hansens disease
Chronic communicable disease of the skin & the peripheral nerves Causative Agent: Mycobacterium Leprae, acid fast bacilli MOT: may be due to prolonged skin-skin contact or droplets IP - years to decades Active immunization (BCG)
Types of Leprosy:
1. Lepromatous or Nodular or Gravis ( most severe) Early s/sx: many lesions or patches 2. Tuberculoid high resistant, less severe 3. Mixed type or Borderline or Dimorphous 4. Indeterminate
TYPES: PAUCIBACILLARY 1. Early/Indeterminate hypopigmented / hyperpigmented anesthetic macules/plaques 2. Tuberculoid solitary hypopigmened hypoesthetic macule, neuritic pain, contractures of hand and foot, ulcers, eye involvement ie keratitis MULTIBACILLARY 1. Lepromatous inability to close eyelids unblinking eyes ( lagophthalmos) multiple lesions, Loss of lateral portion of eyebrows (madarosis), corugated skin (leonine facies), septal collapse (saddlenose) clawing of fingers & toes, loss of digits, enlargement of male breasts ( gynecomastia) 2. Borderline between lepromatous and tuberculoid
Mgt:
Domiciliary home treatment ( RA 4073) Multi Drug Therapy ( MDT) use of 2 or more drugs for the tx of leprosy. Proven effective cure for leprosy & renders patients non-infectious a week after starting treatment. Paucibacillary- Rifampicin and Dapsone Multibacillary-Rifam,Dapsone,Clofazimine Diaminodiphenylsulfone DDS( Dapsone) Rifampicin Clofazimine (lamprene) Treatment is from 9 mos to 18 mos(2 years )
MOT: skin contact, sharing of grooming implements s/sx: nits in hair/clothing, irritating maculopapular or urticarial rash Mgmt: disinfect implements, Lindane (Kwell) topical Permethrin (Nix) topical CX: impetigo to AGN, RHD
Scabies
Sarcoptes scabiei Pruritus (excreta of mites) Mites come-out from burrows to mate at night
MOT: skin contact s/sx: itching worse at night and after hot shower; rash; burrows (dark wavy lines that end in a bleb w/ female mite) in between fingers, volar wrists, elbow, penis; papules and vesicles in navel, axillae, belt line, buttocks, upper thighs and scrotum
Dx: biopsies/scrapings of lesions Mgmt: Permethrin (Nix) cream, crotamiton cream, Sulfur soap, antihistamines and calamine for pruritus, wash linens with hot water, single dose of Ivermectin, treat close contacts
Emerging Diseases
Virus is stable in urine/feces for 1-2 days ; for patient with diarrhea up to 4 days. IP: 2-7 days ( max 10d) Mortality rate 5% only
Clinical criteria :
1. Asymptomatic or mild respiratory illness , fever >38c ( >100.4 F ) 2.One or more clinical finding of respiratory illness
Epidemiologic Criteria:
SARS
Treatment
Antibiotics are ineffective as SARS is a viral disease. supportive with antipyretics, supplemental oxygen and ventilatory support as needed.
Consult doctor promptly early treatment is the KEY Build up good body immunity Maintain good personal hygiene Wear mask if develop runny nose, cough Wear protective mask in public areas Wash hand properly and keep them clean Droplet & contact PRECAUTION
BIRDS FLU
is an AVIAN FLU , a type of influenza known to exist worldwide. Etiologic agent : avian influenza H5N1 strain MOT : spread in air and manure.
Transmitted through contaminated feeds, water, equipment, and clothing No evidence that virus can survive in well cooked meat Spread rapidly among birds not infect human easily No confirmed human-human transmission
Bird Flu
BIRDS FLU
Symptoms in animal vary - can cause death within few days In human same as in human influenza
The highly pathogenic form spreads more rapidly through flocks of poultry. This form may cause disease that affects multiple internal organs and has a mortality rate that can reach 90-100% often within 48 hours.
BIRDSFLU
Vaccines take at least 4 months to produce and must be prepared for each sub-type
Wash hands with soap and warm water for at least 20 seconds before and after handling raw poultry and eggs. Clean cutting boards and other utensils with soap and hot water to keep raw poultry from contaminating other foods. Use a food thermometer to make sure you cook poultry to a temperature of at least 165 degrees Fahrenheit Consumers may wish to cook poultry to a higher temperature for personal preference. Cook eggs until whites and yolks are firm.
FYI
There are only three known A subtypes of influenza viruses (H1N1, H1N2, and H3N2) currently circulating among humans. Influenza A viruses are constantly changing, and they might adapt over time to infect and spread among humans.
END
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Communicable Disease
is an illness due to an infectious agent or its toxic products which is easily transmitted or communicated directly or indirectly from one person or animal to another ** Both infectious and contagious diseases are communicable** **All contagious diseases are communicable but not all communicable diseases are contagious**
Causative Agent:
Mode of Transmission:
1. by contact transmission:
Direct contact immediate direct transfer of microorganism from person to person) Touching, biting, kissing, sexual intercourse
Droplet contact occurs within 3 ft from source ( from coughing, sneezing or talking to an infective person)
2. Indirect transmission
by vehicle route ( through contaminated items)
Serves as an intermediate means to transport & introduce an infectious agent into susceptible host through susceptible port of entry
Fomites
Inanimate objects ( handkerchief, toys, soiled clothes, eating utensils ,surgical instruments, or dressing, IV needle, water, food, milk, serum, plasma
By vector route
Is an animal or flying or crawling insect which serves as an intermediate means of transporting an infectious agent. Ex. Mosquitoes, snails , flies, ticks and others
3. Airborne Transmission:
Droplet neclei ( residue of evaporated droplets that remain suspended in air) Dust particles in the air containing the infectious agent Organisms shed into the environment from skin, hair, wounds or perineal area
Host Factors :
Age, sex, genetics Nutritional status, fitness, environmental factors General physical, mental & emotional health Absent or abnormal immunoglobulins Status of hematopoietic system Presence of underlying disease ( DM, lymphoma, leukemia Pt. treated w/ certain antimicrobials, corticosteroids, irradiation, immunosuppresive agents