INTRODUCTION : INTRODUCTION Respiratory infections : Respiratory infections Slide 3: Every disease has certain weak points susceptible to attack
the basic approach in controlling disease is - to identify their weak points and break the weakest links in the chain of transmission .
This requires sound epidemiological knowledge of the disease. Slide 4: COMMUNICABLE DSEASE
A communicable disease is an illness due to a specific infectious agent or its toxic products arising through transmission of that agent or its product from reservoir to susceptible host, either directly , or from an infected person or animal , or individually through the agency of an intermediate host ,a vector , or the inanimate environment. Slide 5: TYPES OF COMMUNICABLE
Arthropod –borne infections
Surface infections Slide 6: RESPIRATORY INFECTIONS
It refers to any diseases which are caused by pathogenic microbial agents and transmitted through air,.
Airborne disease affects humans get discharged through coughing , sneezing , laughing or through close personal contact. Slide 7: TYPES OF AIRBORNE INFECTIONS:
Acute respiratory infections
Tuberculosis Slide 8: SMALLPOX Slide 9: PUBLIC HEALTH PROBLEM:
In early part of 20th century smallpox was the worldwide distribution
By systematic vaccination and revaccination , it was eliminated from all countries.
Variola – virus major
Human Slide 10: MODE OF TRANSMISSION:
Droplet infection Slide 11: CLINICAL MANIFESTATIONS:
Sudden , onset of high fever
Severe prodormal symptoms followed by appearance of rashes on 3rd day
Centrifugal in distribution Passing through the successive stages of muscle
Leaving behind deep seated
Pock marks permanently Slide 12: DIAGNOSTIC EVALUATION:
Pus culture Slide 13: COMPLICATION:
Bacterial infections at the skin at the lesions
Pitted scars from pustules
Arthritis and bone infections
Pneumonia Slide 14: Severe bleeding
Brain inflammation (encephalitis)
Death Slide 15: PREVENTION AND CONTROL
In 1962, Government of India launched National smallpox eradication program.
In 1975, Govt of India further intensified the program under the banner, operation “smallpox –target zero” within few months , the disease was eliminated
India declared ‘smallpox free country’ in April 1977
the world was declared as smallpox-free
By WHO on 8th may 1980. Slide 16: Even though , smallpox has been eradicated from the world , viruses are being maintained in living conditions only in two laboratories namely US laboratory in Atlanta , Georgia and viral research institute Moscow .
This is because there are many animal pox virus (someday animal pox will replace the smallpox) Slide 17: The epidemiological factors , which favoured the eradication of smallpox are,
Absence of animal reservoir
Absence of subclinical cases
Absence of carrier state
Absence of second attack
Easy recognition of the disease even by a non-medical person
Availability of potent , freeze , dried vaccine
Successful co-operation from the public
Co-operation from the international health organization Slide 18: HUMAN MONKEYPOX Slide 19: PUBLIC HEALTH PROBLEM:
It’s a sporadic disease. 1970 hardly 165 cases were reported from the forest areas of central and west Africa in a space of 15 years.
These areas are under surveillance by WHO
14days Slide 20: MODE OF TRANSMISSION:
Person - person transmission Slide 21: CLINICAL MANIFESTATIONS :
Localized cervical lymphadenopathy , indicating percutaneous route of entry of the virus followed by the appearance of cutaneous rashes .
Among children rashes are extensive and associated with significant mortality.
PREVENTION AND CONTROL:
Vaccination against smallpox protects against monkeypox also, because of its close antigenic resemblance with smallpox virus. Slide 22: CHICKENPOX Slide 23: PUBLIC HEALTH PROBLEM
It is worldwide distribution & occurs in both epidemic and endemic forms
Varicella – zoster . source – case of chickenpox ,a case of herpes zoster (rarely).
Infective materials: Respiratory secretions
Cutaneous lesions and vesicular fluid (scabs not infective) Slide 24: Period of infectivity:1 or 2 days before this appearance of rashes to 4-5 days there after.
Once the macular and papular lesions became pustules , the patient is no longer infectious , because the virus tend to disappear from the lesions .
Secondary attack rate 90%.
Age incidence-Children below 10 years
Occur adult also
Sex – both sexes
Immunity- lifelong immunity Slide 25: Pregnancy
1st trimester -3%, the foetus gets intrauterine infection , resulting severe damage , characterised by LBW, micro-opthalmia , choroidoretinitis , cataract, hypotrophic limbs with hypo toxicity & zoster like skin lesions or scars , congenital vericella syndrome .
Last trimester: only foetus have rashes
During last few days of pregnancy or delivery –severe symptoms will be there
Summer and overcrowding Slide 26: PATHOLOGY:
Virus entered the body through the respiratory route and circulate in the blood.
Later it affects the epidermis part in ballooning
degeneration of the cells and outpouring of the cells and outpouring of the intracellular vesicle.
Very soon the polymorphs migrate from the clear fluid of the vesicle and fluid becomes turbid , the lesions are called pustules , which dry up rapidly resulting in scabs .
Scabs separate within 8–10 days without leaving pock marks . Slide 27: MODE OF TRANSMISSION:
Droplet infection (by droplet and droplet nuclei)
Trans-placental transmission occurs in 3% of cases
Transmission through contaminated fomites is less likely Slide 28: INCUBATION PERIOD:
It is about 15 days , but it varies from 1 – 3 weeks.
PRODORMAL STAGE :
These features are little more severe among adults & lasts for 2 -3 days. Slide 29: It is pre-eruptive stage , characterised by , mild fever , myalgia, & malaise , lasting for about few hours to 1 day Slide 30: EXANTHEMATOUS STAGE:
Appearance of rashes on the next day of the fever or even on the day the fever starts
Macules quickly pass through the papules and vesicles
Pustules and crusting stage within 3-4 days. Lesions are centripetal in distribution . i.e , more on the closed parts of the body (chest , abdomen , axillae). Slide 31: Rashes are pruritic
New lesions continue to appear daily.
Fresh crops of lesions are associated with rise of temperature.
The vesicles look like “water drops” on the skin.
Rashes appear daily for 4-5 days . Slide 32: Pleomorphism of lesions is characteristic of chickenpox i.e all stages of the lesions (macules, papules , vesicles and pustules ) are seen simultaneously at one time.
Lesions can occur in the mouth , forming ulcers .
they can also be seen on cornea , Tympanic membrane and vagina . Slide 33: Crusts (scabs) over the lesions may remain from 1-3 weeks and fall off, not leaving pockmark . however they may be slight discolouration lasting for few weeks before skin becomes normal. Slide 34: COMPLICATIONS:
Its mild disease , self limiting but fatal for babies .
Sepsis due to secondary infection following itching.
Haemorrhages (varicella – haemorrhages)
Rare complications are,
Reye’s syndrome (encephalopathy associated with fatty degeneration of liver)
Congenital vericella syndrome. Slide 35: MANAGEMENT:
Since there is no treatment , patients have to be isolated and managed symptomatically with analgesics , antipyretics and soothing ointments
Concurrent disinfection has to be carried out.
Passive immunization Slide 36: ACTIVE IMMUNIZATON:
A live attenuated virus, freeze dried , vericella vaccine (VARIVAX) has been developed , by using oka-strain of the virus.
It is recommended for the children between 12 months to 12 years ( not for infants) dose -0.5ml, sub-cutaneously.
Efficacy is more than 90 %.
Immunity last for 10-15 years.
Booster dose is not recommended for adults 2 doses are recommended with 4-8 weeks interval.
Pregnancy Slide 37: Malignancy
Long term steroid therapy
This is done by using varicella zoster immunoglobulin (VZIG)
Its given for those , who are at risk such as young close contacts
It is effective when given within 3 to 4 days of exposure
Effective for high risk contacts
Dose 20 units/kg/body wt. Slide 38: ACUTE RESPIRATORY TRACT
INFECTIONS Slide 39: It is the sudden onset of infection of any part of the respiratory system from noses to alveoli including para-nasal sinuses and middle ear and plural cavity.
MAGNITUDE OF THE PROBLEM:
20% of infants born in developing countries fail to survive their 5th birthday and 30% of the child mortality occur because of ARI’s
In India , in absolute members about 2 million deaths among underfives every year. I.e. , 2000 deaths/day or 80/hr or 1/min Slide 40: ARI constitute about 40% of paediatric cases, 20% of hospital admission
25% can managed home by trained members.
CLASSIFICATION OF ARI
Viral –adenovirus, rhinovirus, influenza-v
Bacterial – streptococcus pneumonia , haemo- influenza
Fungal, parasitic, allergic Slide 41: ANATOMICAL CLASSIFICATION
1st group: rhinitis, coryza, sinusitis, otitis media, pharyngitis, tonsillitis, quisy(peritonsillar abcess)
2nd group: epiglotitis, laryngitis, trecheitis, bronchitis, pneumonia, pleurisy
Acute upper respiratory infection (AURI)- includes anatomical first group
Acute lower respiratory tract infection (ALRI) – includes anatomical second group.
Bacteria(LRI) Slide 42: Fungi
Parasites and allergens
Age( underfives, neonates)
Sex (male than females, 1.7:1)
Failure of breastfeeding
Lack of primary immunization
Vitamin A deficiency
Antecedent viral infection Slide 43: ENVIRONMENT:
Air pollution Slide 44: Smoking (active and passive smoking) Slide 45: Winter season Slide 46: Poverty Slide 47: Illiteracy Slide 48: Ignorance Slide 49: Lack of personal hygiene Slide 50: Overcrowding Slide 51: Poor standard of living Slide 52: Lack of sanitation
Non-utilization of health services
MODE OF TRANSMISSION:
Droplet infection Slide 53: INCUBATION PERIOD:
It varies according to etiological factors
PREVENTION AND CONTROL OF ARI
It can be implemented at 1st 3 levels of prevention and namely health promotion , specific protection and early diagnosis and treatment
Other 2 levels of prevention are not implemented because ARI is an acute condition and not a chronic condition Slide 54: HEALTH PROMOTION:
Efficient antenatal care-to reduce the incidence of LBW
Essential care of newborn and special care of LBW newborn.
Promotion of exclusive breast feeding up to first 6 months of life
Improvement in the living conditions (housing and sanitation)
Reduction of parental smoking and smoke pollution indoors
Limiting the size of the family to prevent over crowding
Health education of mothers about correct ARI case management at home within the following points
To increase feeding and to keep the child warm Slide 55: To clear the nose by instillation of breast milk , if runny nose interferes with feeding.
To relieve the cough with home made decoctious like tea, ginger, lime juice etc.,
To recognize danger signs such as fast breathing ( chest in-drawing).
Strengthening the existing routine primary immunization such as measles vaccine, HIB vaccine, pneumococcal pneumonia vaccine.
Oral vitamin A concentrate , 5 mega doses for children between 9 months to 3 years
Other vaccines which can be given are pneumocaccal and hemophillus –B vaccine. Slide 56: EARLY DIAGNOSIS AND TREATMENT:
Age of the child
Duration of cough
Chest in-drawing- is lower chest wall moving during inspiration
Fast breathing – this is considered to be present when the respiratory rate is as follows.
-60/min or more , in a child below 2 months of age.
-50/min or more , in a child between 2 to 12 months of age
-40/min or more in a child between 1-5 years of age.
-Infant stopped feeding well (<2months) Slide 57: Ability to drink ( 2months to 5 years)
Malnutrition ( one of the risk factor and case fatality rate is higher).
Cyanosis and any history of treatment (hypoxia)
Wheezing ( whistling noise heard during expiration , due to narrowing of air passage).
CLASSIFICATION OF ILLNESS & TREATMENT:
Very severe disease
Pneumonia (not severe)
No pneumonia (cough and cold) Slide 58: MANAGEMENT OF PNEUMONIA WITH THE AGE GROUP OF 2 MONTHS UPTO 5 YEARS:
(if also recurrent wheezing go directly to treat wheezing) Slide 59: treatment:
refer urgently to hospital-give first dose of an antibiotic
treat fever and wheezing, if present , if referral is not feasible treat with antibiotic Slide 60: PNEUMONIA:
No chest in-drawing and fast breathing (50/min or more if child 2 months to 12 months , 40/min if the child 12 months to 5 years )
Advice mother to give home care
Give an antibiotic
Treat fever , if present
Treat wheezing if present
Advise mother to return with child in 2 days for reassessment , or earlier if the child is getting worse. Slide 61: NO PNEUMONIA:
Signs- Cough and cold
No chest in-drawing and no fast breathing (less than 50/min if child 2 months up to 12months , less than 40/min if child is 12 months up to 5 years )
If coughing more than 30 days , refer for assessment
Assess and treat ear problem or sore throat , if present
Assess and treat other problems Slide 62: Advise mother to give home care , treat fever , if present
Treat wheezing if present
(reassess in 2 days a child who is taking an antibiotic for pneumonia )
DANGER SIGNS OF SEVERE
Stridor when calm
Stopped feeding well
Fever or low body temperature Slide 63: DRUGS FOR PNEUMONIA:
Co-Trimaxozole is the drug of choice for the treatment of pneumonia
Age /wt - <2months (wt – 3-5 kg) Paediatric tablet- Sulphamethaxazole-100 mg and Trimethoprim-20 mg- one tab/2days Slide 64: -Paediatric syrup-each spoon (5ml) , sulphomethoxazole-200mg and Trimethoprim 40mg–half spoon (2.5ml) twice a day.
2-12 months ( wt – 6-9 kg) -Tablets-2tab/2days: Syrup- one spoon (5ml) twice a day
1-5 years ( wt 10- 19 kg) – 3 tab/2days; 1 ½ spoon (7.5 ml) for 2 days
Intramuscular injection of benzyl penicillin (after test dose) , Ampicillin, and Chloramphenicol.
Condition should be monitored everyday and reviewed after 48 hours. Slide 65: FOR 2 TO 5 YEARS
1st 48 hrs
benzyl penicillin – 50,000 IU/kg dose- 6hrly- IM
chloramphenical – 25mg/kg/dose-6hrly-IM
1) if condition improves, then for the next 3days give:
Procaine penicillin – 50,000 IU/kg (max 4lac IU)-once–IM
Ampicillin – 50mg/kg/dose – 6 hrly- oral
Chloramphenicol – 25mg /kg/dose-6hrly-oral Slide 66: b)2) if no improvement , then for the next 48hrs (change antibiotic)
if chloramphenicol is used , change to cloxacillin 25mg/kg/dose, every 6 hours along with gentamycin 2.5 mg/kg/dose , every eight hours.
If condition improves continue treatment orally
c) Provide symptomatic treatment for fever and wheezing , if required
d) monitor fluid and food intake
e) advise mother on home management on discharge . Slide 67: MANAGEMENT OF AURI
Many children with presenting symptoms of cough , cold and fever do not have pneumonia (no fasting breathing or chest in-drawing )
Do not require treatment with antibiotics .
Symptomatic treatment and care at home is generally enough for such cases. The mother must be advised on how to take care of the child at home. Slide 68: DRUGS FOR INFANTS UNDER 2 MONTHS OF AGE:
Inj. Benzyl penicillin – 50000 IU /kg/ dose – if age <7yrs (Q12H)-if age 7days to 2 months (Q6H).
Inj. Ampicillin – 50mg/kg/dose – if age <7yrs(Q12H)- if age 7days to 2 months (Q8H)
Inj.GM – 2.5 mg/kg/dose – if age <7yrs (Q12H)- if age 7 days to 2 months(Q8H). Slide 69: MEASLES Slide 70: PROBLEM STAEMENT:
Global problem , in India , it is the 3rd most common cause of death among underfives.
1987, 2.5 lakh, cases were reported
2000 , hardly 25,000 cases were reported .
Measles is known for its epidemicity in cyclic trend.
Paramyxo virus- cannot survive outside the human body. It can easily be destroyed by heat , acid and drying. Slide 71: HOST:
Age (6months to 3 yrs)
Sex (both sexes)
Immunity (life long immunity)
Nutritional status (malnutrition)
Early spring (January to April)
Poor environmental condition
Poor housing Slide 72: PATHOGENISIS:
Organism entered through respiratory tract by droplet infection
Passes through lymph nodes, multiply and leak into the bloodstream & small amount reach in liver , spleen and bone-marrow . where they multiply and destroy and flow again into blood stream.
Affects respiratory mucosa ( conjunctiva , nose , throat, bronchial tree ) , skin. Slide 73: INCUBATION PERIOD:
10 days between the onset of infection and the appearance of rashes
PERIOD OF COMMUNICABILITY:
4 days and 5 days after the appearance of rashes.
SECONDARY ATTACK- 80%
MODE OF TRANSMISSION:
Conjunctival route Slide 74: CLINICAL FEATURES
PRODORMAL STAGE (PRE-ERUPTIVE STAGE (OR) CATARRHAL STAGE)
Anorexia Slide 75: Cough
Lacrimation Slide 76: Conjunctival congestion Slide 77: Photophobia Slide 78: Swelling of lower lids Slide 79: Runny nose Slide 80: Flushing of the face Slide 81: Nausea
1 or 2 days koplik spots present
Small , blush white spots on a red base
Often cervical lymphadinopathy
Febrile convulsions occur last for 3 days
ERUPTIVE STAGE :
Rashes appear on 4th day of fever
First behind the ears , forehead and lower extremities Slide 82: Rashes are pink coloured , velvety & maculo – papular.
At this stage temperature will be high about 104* F for 1 or 2 days
5 or 6th day rashes become disappear completely from face but not leave in trunk
Brownish discolouration which persist for 6 to 8 weeks
No permanent pock mark behind Slide 83: COMPLICATIONS:
Post measles complication :
Respiratory complications – pneumonia
- otitis media
GI complications-gastro enteritis
-malnutrition Slide 84: neurological complications – febrile convulsions
Sub-acute sclerosing pan-encephalitis (virus enter into brain cause disorientation paralysis , and death)
ophthalmic convulsions – conjunctivitis
- corneal ulceration Slide 85: MANAGEMENT:
Isolation Slide 86: Disinfection of nasal and throat secretions Slide 87: Q4H – TPR chart Slide 88: Tepid sponge Slide 89: Light and clean cloths Slide 90: Eye should washed with sterile water saline Slide 91: Antipyretics Slide 92: Attendants to use gown and mask Slide 93: Prophylactic antibiotics Slide 94: Should drink plenty of water and fruit juice
Watch for complications
Terminal disinfection of the room Slide 95: PREVENTION
IMMUNIZATION Slide 96: ACTIVE IMMUNIZATION
Live attenuated vaccine
2 groups – aerosolized vaccine
- heat stable vaccine( single antigen)
- MMR vaccine ( multiple antigens)
-0.25 to 0.5 ml/kg body wt
-Immunity lasts for 3 weeks Slide 97: ADVERSE EFFECTS:
Mild measles illness in 15 to 20 % of the recipients 1 in 1 million vaccines
Anaphylactic shock is very rare
Toxic shock syndrome Slide 98: RUBELLA (GERMAN MEASLES) Slide 99: PROBLEM STATEMENT:
1964-65 when nearly , 12.5 million
Late winter season Slide 100: CLINICAL FEATURES:
PRODORMAL STAGE :
Usually the symptoms are mild
Coryza (common cold)
Lastng for a day or 2 days
Lymphadenopathy: Post auricular and posterior group of cervical lymph nodes about 10-15 days after the disappearance of the rashes
EXANTHEMATOUS STAGE :
Maculo papular rashes appear on 1st 24 hrs.
Small, pale , pinkish , discreet spots
3rd day disappear in face Slide 101: COMPLICATIONS:
Congenital malformation of foetus in a pregnant mother
MODE OF TRANSMISSION:
15-20 days Slide 102: PATHOGENISIS:
Entered the body through respiratory route, reach the cervical group of lymph nodes
Multiply and develop rashes
When virus enter the foetus via the placenta
Damage the organ because of organogenisis of the foetus Slide 103: DIAGNOSIS:
Throat swab Slide 104: Serological investigation (1st sample drawn from 5days onset of illness and 2nd sample after 2 weeks later) Slide 105: ELISA
Radio immune assay.
(RUBELLA SYNDROME) Slide 106: It refers to infants born with a number of defects due to intrauterine infection with rubella virus , occurring early part of the foetal life.
Since the foetus is in the stage of organogenesis , the rubella infection inhibits cell division , resulting multiple structural defects. Slide 107: Congenital rubella, chronic infection while acquired rubella is acute infection .
Stages risks of damage to
the foetus (%)
4-8 weeks 80%
8-12 weeks 25%
12-16 weeks 10%
>17 weeks 00% Slide 108: Cataract
Damages of eyes, heart, ears
Hypospadiasis Slide 109: PREVENTION:
All vaccines are monovalent vaccines and combined vaccines
All are freeze dried vaccines supplied along with diluent , i.e. , sterile distilled water
They are live attenuated vaccines
Dose – 0.5 ml, SC in left upper arm.
Storage temperature is 2 to 8*c
Immunity last for 15 yrs
Contraindicated for pregnant mothers Slide 110: PASSIVE IMMUNIZATION:
Done by human normal immunoglobulin
Usually for pregnant mothers
Dose -20ml, intramuscularly, its use is optional.
Therapeutic abortion is a better way of prevention of congenital rubella.
. Slide 111: MUMPS Slide 112: PROBLEM STATEMENT :
Acute infectious self limiting disease caused by RNA virus
RNA virus.- belonging to myxovirus group
Infective materials (salivary secretions of the reservoirs)
Immunity (life long immunity) Slide 113: ENVIRONMENT:
During winter season
Poor living condition
Endemic disease often in epidemics.
PERIOD OF COMMUNICABILITY:
Usually 6-8 days before and after clinical onset of disease ie , after enlargement of the parotid gland .
Secondary attack – 80-90%
MODE OF TRANSMISSION
Droplet infection Slide 114: CLINICAL FEATURES:
Sudden onset of fever Slide 115: Associated with headache Slide 116: Body ache Slide 117: Malaise Slide 118: Associated with earache Slide 119: Lasting for 1 to 2 days followed by painful enlargement of one or both parotid gland
Tenderness in the parotid gland Slide 120: Difficulty in opening the mouth
Sublingual and sub- mandibular gland may also be affected Slide 121: COMPLICATIONS:
-Live attenuated highly potent and effective to the tune of 90-95%
-Dose – 0.5ml , SC (or) IM
-MMR vaccine Slide 122: CONTROL:
Control of mumps is difficult
However the cases should be isolated and concurrent disinfection is carried out Slide 123: INFLUENZA Slide 124: PROBLEM STATEMENT:
Its a international disease
It can occur sporadic , endemic , epidemic and pandemic form.
In 20th century it caused 3 pandemics
At present 3 types of virus present – A (H1N1)
In recently , influenza A(H1N1) virus of swine origin emerged in Mexico during the spring of 2009
As of worldwide 2010, about 18,156 deaths due to this pandemic has been reported worldwide. Slide 125: EPIDEMIOLGICAL TRAID:
Major reservoir is animals and birds
Infected respiratory tract secretions
Period of communicability -Nasopharynx from 1 or 2 days before and 1 or 2 days after onset of symptoms
Age and sex (all ages and both sexes)
Season – winter season
Overcrowding (eg.,) schools, instituitions, ships.etc., Slide 126: MODE OF TRANSMISSION:
Person to person by droplet infection or droplet nuclei
Mainly through respiratory tract
Virus enters the respiratory tract
Inflammation and necrosis of superficial epithelium of tracheal and bronchial mucosa
Symptoms occur Slide 127: CLINICAL FEATURES:
Aches and pains
Fever lasts from 1-5 days , averaging in 3 days in adults
Frequent complications are acute sinusitis , otitis media
Rare complications:Reye’s syndrome (fatty liver with encephalopathy ) occur in children Slide 128: DIAGNOSTIC EVALUATION:
VIRUS ISOLATION :
Through nasopharyngeal secretions
The virus can be detected by the indirect fluorescent antibody technique.
After that Antigen analysis was done.
Haemagglutination inhibition (HI)
ELISA Slide 129: PREVENTION:
Good ventilation of public buildings Slide 130: Cover the face with handkerchief when coughing and sneezing Slide 131: Immunization Slide 132: Hygienic practices during handling of poultry products including hand washing and prevention of cross contamination Slide 133: VACCINES:
KILLED VACCINES :
The recommended vaccines was developing chick embryos , harvested, purified , killed by formalin or beta-propiolactine and standardized according to haemagglutinin content
SC or IM
Adult and child >3yrs should provide 0.5 ml
Child with 6 months to 36 months will provide 0.25ml
Immunity last for 6-12 months
Revaccination every year Slide 134: LIVE ATTENUATED VACCINE:
A trivalent live attenuated vaccine administered single dose nasal spray is effective
Should given for 2 years and 49 years old people
Not recommended for immuno-supressed individuals Slide 135: ANTIVIRAL DRUGS:
Oseltamivir – 75 mg / day Prophylaxis
And twice day for 5 days in therapy
Zanamivir by inhaler (10mg dose) twice daily for therapy and once daily for prophylaxis
Influenza A –treated with zanamivir or combination of oseltamivir and rimantadine
Influenza-B-cab be treated with either oseltamivir or zanamivir . Slide 136: AVIAN INFLUENZA
Avian influenza refers to a large group of different influenza viruses that primarily affects birds.
In rare occasions, this virus may spread to other species , including pigs and humans.
Its pandemic(H5N1 virus)
When the virus was enter into the human – it will be a human influenza virus Slide 137: First infected person is in hong kong in 1997. causing 18 cases with 6 deaths
Since 2003, caused large outbreaks
Then, from 1st oct, 2009 to 17th feb, 2010, 16 human cases of H5N1 influenza A were reported from Cambodia , Egypt and Vietnam
Fortunately, this virus not spread to humans from birds or spread readily among humans.
If its emerges , its global spread its considered inevitable Slide 138: The virus could spread more rapidly , possibly reaching all continents in less than 3 months.
PANDEMIC (H1N1) 2009 INFLUENZA
This influenza infects the lower respiratory tract infections and rapidly causing progressive pneumonia , especially young child and young to middle age.
2009, (H1N1) spread throughout the world Slide 139: In India , new cases will increase , particularly in Maharashtra , and lesser extent in AP, Gujarat , MP, Delhi , Karnataka.
India , has reported nearly 37,000 (H1N1) 2009 cases and 1833 deaths.
2-3 days can range from up-to 7 days.
Influenza like illness (ILI) :
Sore throat Slide 140: Rhinorrhea
Muscle pain and malaise
GI illness also present:
Vomiting mainly in children
Encephalopathy Slide 141: Encephalitis
Other complications like, - Rhabdomylosis
Chronic hepatic and renal failure
Other cardio vascular disease (chronic) Slide 142: SIGNS AND SYMPTOMS OF
Uncomplicated influenza may progress to severe complicated pneumonia
If progression occur urgent referral within 24 hours
s/s of cardiopulmonary insufficiency :
shortness of breath
bloody or coloured sputum
<BP Slide 143: s/s with CNS complications
altered mental status
invasive 2ry bacterial infection based on laboratory testing
severe dehydration , manifested as decreased activity , dizziness , decreased UO and lethargy. Slide 144: RISK FACTORS FOR SEVERE DISEASE:
Infants , young children in particular <2 years
Persons with asthma or chronic pulmonary disease and chronic cardiac disease
Persons with metabolic , chronic renal disease and neurological conditions and seizures
Children receiving chronic aspirin therapy
>65 yrs Slide 145: LABORETORY DIAGNOSIS:
RT-PCR- reverse transcriptase chain reaction
Respiratory samples combination of para-pharyngeal samples and throat swabs
Hand hygiene (soap & water, strict alcohol based sanitizer)
Cover mouth and nose while cough and sneeze
Should follow aseptic method while doing any procedures (bronchial scopy., etc)
Special attention needed for immuno-supressed patients Slide 146: VACCINES:
They all supplied in multi dose vials
Single dose . 0.5ml- in upper arm , for infants thigh is preferred site
LIVE ATTENUATED VACCINE:
Can given via nasal spray
WHO suggestion for vaccine:
Individuals with age more than 6 months
Healthy adults and healthy children Slide 147: TREATMENT:
Symptomatic treatment Slide 148: Anti viral drugs
Antimicrobials Slide 149: O2 therapy Slide 150: Saturation monitoring Slide 151: Fluid replacement Slide 152: ANTIVIRAL THERAPY:
Oseltamivir is indicated for treatment of influenza
For adults –dose is -75mg /twice day for 5 days
>3-12 months - 3mg/kg, twice daily for 5 days
>1-3 months - 2.5mg/kg, twice daily for 5 days
0- month - 2mg/kg , twice daily for 5 days Slide 153: For older children
15kg or less 30 mg twice a day for 5 days
14-23 kg 45 mg ‘’ “ ‘’ “ “
24-40 kg 60 mg “ “ “ “
>40 kg 75 mg “ “ “ “
Zanamivir is indicated for treatment of influenza in adults and children (>5 yrs) .
The recommended dose for treatment of children and adults from the age of 5 yrs is two inhalations (2 5 mg) twice daily for 5 days. Slide 154: DIPTHERIA Slide 155: PROBLEM STATEMENT:
It is eliminated from other developed countries of the world mainly mass immunization but not in developing countries
Recent outbreaks in Ukraine (1990) , Thailand and laos (1996) with the age group of 5 -15 years
WHO reported that , 5000 deaths during 2002, in India,
It was decreased because of immunization program. Slide 156: EPIDEMIOLOGICAL TRAID:
Human is the reservoir of infection
Age (1-5 yrs)
Sex ( both)
Immunity ( breast-fed infants are immune )
Indoor life and over crowding Slide 157: MODE OF TRANSMISSION:
Indirect contact ( contaminated fomites)
PERIOD OF INFECTIVITY:
2-6 days occasionally longer Slide 158: PATHOGENISIS:
The bacilli entered and passed through the tonsils , nasopharynx, or larynx and multiple
Superficial epithelial cells get necrosis
The exudates containing fibrin clots, living bacilli, leukocytes which is greyish color and adherent to underlying tissues
About 1-3 mm thick Slide 159: CLINICAL FEATURES:
NASAL DIPTHERIA :
Usually anterior part of the throat is affected
It is thin and watery to start and later purulent and blood stained
The nasal discharge may produce denudation of the external nares and upper-lip Slide 160: TONSILAR DIPTHERIA:
Pain in the throat
Difficulty in swallowing
Fowl smelling comes from the infected mouth
Surrounding tissues oedematous and enlarged
Lymph nodes are enlarged and tender Slide 161: PHARYNGEAL DIPTHRIA: (FAUCIAL DIPTHERIA)
The child will have dry , disturbed , cough , sore throat and pain in the throat.
Fowl smell from the mouth
Congestion and oedematous of the pharynx
Severe fever, restless , irritable, looks pale , drowsy , the skin is dry and hot , pulse is rapid and thready. Slide 162: LARYNGEAL DIPTHERIA:
Hoarseness of the voice
Laryngeal stridor Slide 163: OTHER RARE FORMS OF DIPTHERIA’S ARE:
Cutaneous diphtheria characterised by punched ulcer in the skin and absence of features of toxaemia
Gastro intestinal diphtheria
Endocardiac diphtheria Slide 164: CONTROL OF DIPTHERIA
Early detection – searching in schools and do lab examination for confirmation
Isolation- all carriers and cases should be isolated for at least 14 days
Cases: should give diphtheria anti toxin without delay – the dose can vary depending upon the severity of the cases (20,000- 1,00,000 units or more – IM or IV after the test dose)
For mild pharyngeal disease – 20,000-40,000 units
For moderate laryngeal disease – 40,000-60,000 units
For severe disease – 80,000-1,00,000 units Slide 165: Carriers: The carriers should be treated with 10 days course of oral erythromycin , which is most effective treatment of carriers
Primary immunization or booster dose was received within the previous 2 years – no further action would be needed.
Primary immunization and booster dose was received more than 2 yrs – need booster dose of DT
Non-immunized closed contacts should receive prophylactic penicillin or erythromycin (1000-2000 units of DT) Slide 166: DIPTHERIA IMMUNIZATION:
CURRENT PROPHYLAXIS:(COMBINED VACCINES)
DPT (diphtheria –pertusis-tetanus vaccine)
DTPw ( diphtheria –tetanus, whole cell pertusis)
DTPa ( diphtheria –tetanus –acellular pertusis)
DT (diphtheria – tetanus toxoid)
dT (diphtheria- tetanus , adult type) Slide 167: storage:DPT/DT- should be in frozen (4 to 8 degrees)
Age: 6 weeks after the birth
Number of doses: 3 doses of DPT of which is usually 0.5 ml
Interval: 5 weeks between 3 doses, booster dose at 1 to 2 year. Followed by another booster (DT) at the age of 5-6 years.
Mode of administration: deep IM ( upper outer quadrant of the gluteal region)
Later its administer in later aspect of the thigh
Reaction- fever, mild local reactions
Contraindications – cough, cold , mild fever Slide 168: SINGLE VACCONES:
FT (formal toxoid)
APT (alum-precipitated toxoid)
PTAP (purified toxoid aluminium phosphate)
PTAH (purified toxoid aluminium hydroxide)
TAF ( toxoid – anti toxin fluccules)
These single vaccines are less frequently used
Each dose contains 25 loefflers (LF) units in DT
Diptheria vaccine (prepared from horse serum) Slide 169: WHOOPING COUGH
Chinese call it is a ‘hundred day cough’ Slide 170: PROBLEM STAEMENT
Pertussis is an important cause of death in infants worldwide, and continues to be a public health concern even in countries with high vaccination coverage.
Estimate from WHO suggests that in 2008 , about 16 million cases of pertussis occurred worldwide , 95% of which were in developing countries
In India , there is marked decline of the disease after launch of universal immunization programme During the year 1987, the reported 2009 only 55,074 cases were reported showing decline of about 67%. Slide 171: EPIDEMILOGICAL TRAID:
Certain viruses, adenovirus , parainfluenza virus
It infects only man
Age- below 5 years
Often unrecognised because of atypical course
Sex- more among female than male children
Immunity- adequate immunization followed by immunity Slide 172: ENVIRONMENT;
Poor socio economic status
MODE OF TRANSMISSION:
Fomites in the spread of infection appears to be very small , unless they are freshly contaminated
Usually 7- 14 days, but not more than 3 weeks Slide 173: CLINICAL FEATURES
Lasting about 10 days
Sneezing and corynea
Hacking neck cough that becomes diurnal Slide 174: PAROXYSMAL STAGE:
Lasting for 2-4 weeks
Bursts of rapid ,Consecutive coughs followed by vomiting
High pitched inspiration
Cyanosis and apnoea in young infants
Persistent cough in adults and adolescents
CONVALESENT STAGE :
Lasting for 1-2 weeks , the illness generally lasts 6-8 weeks Slide 175: COMPLICATIONS:
It occur 5-6 % of cases ,
Chief complaints of pertussis are
Sub-conjunctival haemorrhage epistaxis
Cerebral haemorrhage which cause convulsions and coma Slide 176: CONTROL
Early diagnosis-bacteriological examination, fluorescent antibody technique
Treatment- 30-50 mg /kg of body weight in 4 divided doses for 10 days (Ampicillin, Septran or tetracycline)
Prophylactic antibiotic (erythromycin or ampicillin) treatment for 10 days to prevent the infecting bacteria to become established. Slide 177: IMMUNIZATION:
By administering 3 doses ( each dose about 0.5ml) of DPT vaccine IM , at one month interval , starting at the age of 6 weeks.
Commercially available vaccines containing acellular pertussis include combination of DT,TT, HiB , Hep B, and IPV
Rare vaccines reactions are,
Hypotonic hypo-responsive episodes
Encephalopathy Slide 178: Contraindications:
Personal or strong family history of epilepsy
Convulsions or similar CNS disorder
Hyper-immune globulin in pertussis prophylaxis has yet to be established. Slide 179: MENINGOCOCCAL MENINGITIS Slide 180: PROBLEM STATEMENT
Each year there are estimated 300,000-500,000 cases of meningococcal disease and about 3-6 thousand deaths .
Meningococcal disease is endemic in India
Cases of meningococcal meningitis are reported sporadically or in small clusters.
During 2009, about 6386 cases of meningococcal meningitis were reported in India with about 460 deaths Slide 181: Reported cases due to meningococcal meningitis in India 2009:
States cases Deaths
AP 1112 9
MP 403 18
UP 56 8
Delhi 239 13
West Bengal 1977 307
Maharashtra 126 0
Karnataka 1078 5
Kerala 197 1
TN 167 2
Total 6386 460 Slide 182: EPIDEMIOLOGICAL TRAID:
N.meningitis is a gram negative diplococci
Source of infection – nasopharynx of cases and carriers
Age and sex – children and young adults of both sexes.
Immunity - immunity is acquired by subclinical infection (mostly)
Dry and cold months of the year
Low socio economic groups living under poor housing conditions Slide 183: MODE OF TRANSMISSION:
3-4 days but may vary from 2-10 days
SIGNS AND SYMPTOMS:
Various neurological signs Slide 184: CONTROL
Treatment with antibiotics
Penicillin is the drug of choices
Inj.penicillin – allergic patients , ceftriaxone and other 3rd generation cephalosporins should be substituted
Rifampicin are needed to eradicate the carrier state
Chemoprophylaxis suggested for close friends
Rifampicin-600 mg twice a day for adults or minocycline-100 mg every 12 hours. Slide 185: MASS CHEMOPROPHYLAXIS:
The other drugs are ciprofloxacin , minocycline , spiramycin and ceftriaxone.
Internationally licensed meningococcal vaccine are bivalent or tetravalent
Single dose-50mg, of each of the individual polysaccharides.
It is estimated that , a mass immunization campaign , if promptly implemented can avoid 70% of cases. Slide 186: ENVIRONMENTAL MEASURES:
Improved housing and prevention of overcrowding are long –term measures Slide 187: SEVERE ACUTE RESPIRATORY
INFECTIONS Slide 188: PROBLEM STATEMENT:
The earliest case was treated to a health care worker in china , in late 2002, with rapid spread to Hong-Kong, Singapore, Taiwan, and Toranto
As of early august 2003, about 8,422 cases were reported to the WHO from 30 countries with 916 fatalities.
2-7 days , commonly 3-5 days Slide 189: MODE OF TRANSMISSION:
Direct or indirect contact of mucous membrane of eyes, nose or mouth with respiratory droplets or fomites.
The use of aerosol –generating procedures (endotracheal intubation , bronchoscopy, nebulisation ) in hospitals may amplify the transmission of the SARS coronovirus.
The SARS virus can survive for hours on common surfaces outside the human body, and up to 4 days in human waste.
24 hours last for in plastic surface , at room temperature & can live extended periods in cold Slide 190: DIAGNOSTIC TESTS REQUIRED FOR LABORATORY CONFIRMATION OF
Conventional reverse transcriptase PCR (RT-PCR)
Real-time reverse transcriptase PCR (real-time RT-PCR) for detecting viral RNA
ELISA and immunoflurescent assay (IFA)
Tension – pneumothorax
Non-cardiogenic pulmonary oedema
20-30% of patients who having ARDS require intubation and mechanical ventilation Slide 191: TREATMENT:
Severe case required intensive support
Ribavirin (400-600 mg/day and 4g/day)
Mortality rate is 14%
1% persons under 24 years of age
>50% in persons over 65 years. Slide 192: PREVENTION:
Prompt identification of persons with SARS their movements and contacts
Effective isolation of SARS patients in hospitals
Appropriate protection of medical staff treating these patients
Comprehensive identification and isolation of suspected SARS cases Slide 193: Simple hygienic measures such as hand washing after touching patients , use of appropriate and well fitted masks, are the introduction of infection control measures. Slide 194: Exit screening of international travellers
Timely and accurate reporting and sharing of information with other authorities and/or governments . Slide 195: THANK YOU