Respiratory infections

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INTRODUCTION : 

INTRODUCTION

Respiratory infections : 

Respiratory infections

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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.

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COMMUNICABLE DSEASE DEFINITION 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.

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TYPES OF COMMUNICABLE DISEASES Respiratory infections Intestinal infections Arthropod –borne infections Zoonosis Surface infections

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RESPIRATORY INFECTIONS (AIRBORNE DISEASES) 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.

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TYPES OF AIRBORNE INFECTIONS: Smallpox Chickenpox Measles Rubella Mumps Influenza Diphtheria Whooping cough Meningococcal meningitis Acute respiratory infections SARS Tuberculosis

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SMALLPOX

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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. EPIDEMIOLOGICAL TRAID: Agent: Variola – virus major Host: Human

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MODE OF TRANSMISSION: Droplet infection

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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 Paplule Vessicle Pustule Scab formation Leaving behind deep seated Pock marks permanently

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DIAGNOSTIC EVALUATION: Serological test Pus culture

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COMPLICATION: Bacterial infections at the skin at the lesions Pitted scars from pustules Arthritis and bone infections Pneumonia

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Severe bleeding Eye infections Brain inflammation (encephalitis) Death

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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.

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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)

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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

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HUMAN MONKEYPOX

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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 INCUBATION PERIOD: 14days

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MODE OF TRANSMISSION: Person - person transmission

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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.

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CHICKENPOX

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PUBLIC HEALTH PROBLEM It is worldwide distribution & occurs in both epidemic and endemic forms EPIDEMIOLOGICAL TRAID: AGENT Varicella – zoster . source – case of chickenpox ,a case of herpes zoster (rarely). Infective materials: Respiratory secretions Cutaneous lesions and vesicular fluid (scabs not infective)

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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%. HOST: Age incidence-Children below 10 years Occur adult also Sex – both sexes Immunity- lifelong immunity

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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 ENVITRONMENTAL FACTORS: Summer and overcrowding

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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 .

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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

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INCUBATION PERIOD: It is about 15 days , but it varies from 1 – 3 weeks. CLINICAL MANIFESTATIONS: PRODORMAL STAGE : These features are little more severe among adults & lasts for 2 -3 days.

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It is pre-eruptive stage , characterised by , mild fever , myalgia, & malaise , lasting for about few hours to 1 day

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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).

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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 .

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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 .

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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.

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COMPLICATIONS: Its mild disease , self limiting but fatal for babies . Sepsis due to secondary infection following itching. Varicella-pneumonia Encephalitis Haemorrhages (varicella – haemorrhages) Rare complications are, Reye’s syndrome (encephalopathy associated with fatty degeneration of liver) Congenital vericella syndrome.

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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. PREVENTION: Active immunization Passive immunization

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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. CONTRAINDICATIONS: Pregnancy

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Malignancy AIDS Long term steroid therapy PASSIVE IMMUNIZATION: 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.

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ACUTE RESPIRATORY TRACT INFECTIONS

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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

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ARI constitute about 40% of paediatric cases, 20% of hospital admission 25% can managed home by trained members. CLASSIFICATION OF ARI Etiological classification Anatomical classification WHO classification ETIOLOGICAL CLASSIFICATION: Viral –adenovirus, rhinovirus, influenza-v Bacterial – streptococcus pneumonia , haemo- influenza Fungal, parasitic, allergic

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ANATOMICAL CLASSIFICATION 1st group: rhinitis, coryza, sinusitis, otitis media, pharyngitis, tonsillitis, quisy(peritonsillar abcess) 2nd group: epiglotitis, laryngitis, trecheitis, bronchitis, pneumonia, pleurisy WHO CLASSIFICATION; Acute upper respiratory infection (AURI)- includes anatomical first group Acute lower respiratory tract infection (ALRI) – includes anatomical second group. EPIDEMIOLOGICAL TRAID: AGENT: Virus(URI) Bacteria(LRI)

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Fungi Parasites and allergens HOST: Age( underfives, neonates) Sex (male than females, 1.7:1) LBW Failure of breastfeeding Under nutrition Lack of primary immunization Vitamin A deficiency Antecedent viral infection

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ENVIRONMENT: Air pollution

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Smoking (active and passive smoking)

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Winter season

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Poverty

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Illiteracy

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Ignorance

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Lack of personal hygiene

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Overcrowding

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Poor standard of living

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Lack of sanitation Non-utilization of health services MODE OF TRANSMISSION: Droplet infection

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INCUBATION PERIOD: It varies according to etiological factors PREVENTION AND CONTROL OF ARI PREVENTION: 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

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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

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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). SPECIFIC PRODUCTION: 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.

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EARLY DIAGNOSIS AND TREATMENT: (CONTROL) ASSESSMENT: Age of the child Duration of cough Chest in-drawing- is lower chest wall moving during inspiration Stridor 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)

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Ability to drink ( 2months to 5 years) Malnutrition ( one of the risk factor and case fatality rate is higher). Excessive drowsiness Convulsions Irregular breathing 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 Severe pneumonia Pneumonia (not severe) No pneumonia (cough and cold)

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MANAGEMENT OF PNEUMONIA WITH THE AGE GROUP OF 2 MONTHS UPTO 5 YEARS: SEVERE PNEUMONIA: Signs: Chest in-drawing nasal flaring Cyanosis (if also recurrent wheezing go directly to treat wheezing)

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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

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PNEUMONIA: Signs : 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 ) Treatment: 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.

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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 ) Treatment: If coughing more than 30 days , refer for assessment Assess and treat ear problem or sore throat , if present Assess and treat other problems

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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 PNEUMONIA: Convulsions Stridor when calm Stopped feeding well Wheezing Fever or low body temperature

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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

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-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 SEVERE PNEUMONIA: Intramuscular injection of benzyl penicillin (after test dose) , Ampicillin, and Chloramphenicol. Condition should be monitored everyday and reviewed after 48 hours.

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FOR 2 TO 5 YEARS ANTIBIOTICS: 1st 48 hrs benzyl penicillin – 50,000 IU/kg dose- 6hrly- IM or Ampicillin -50mg/kg/dose-6hrly-IM or 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 Or Ampicillin – 50mg/kg/dose – 6 hrly- oral Or Chloramphenicol – 25mg /kg/dose-6hrly-oral

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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 .

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MANAGEMENT OF AURI (NO PNEUMONIA) 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.

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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).

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MEASLES

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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. EPIDEMIOLOGICAL TRAID: AGENT: Paramyxo virus- cannot survive outside the human body. It can easily be destroyed by heat , acid and drying.

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HOST: Age (6months to 3 yrs) Sex (both sexes) Immunity (life long immunity) Nutritional status (malnutrition) ENVIRONMENTAL : Winter season Early spring (January to April) Overcrowding Poor environmental condition Poor housing

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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.

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INCUBATION PERIOD: 10 days between the onset of infection and the appearance of rashes INFECTIVE MATERIALS: Respiratory secretions PERIOD OF COMMUNICABILITY: 4 days and 5 days after the appearance of rashes. SECONDARY ATTACK- 80% MODE OF TRANSMISSION: Droplet Conjunctival route

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CLINICAL FEATURES PRODORMAL STAGE (PRE-ERUPTIVE STAGE (OR) CATARRHAL STAGE) Fever Anorexia

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Cough Lacrimation

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Conjunctival congestion

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Photophobia

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Swelling of lower lids

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Runny nose

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Flushing of the face

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Nausea Vomiting Dry cough 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

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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

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COMPLICATIONS: Post measles complication : Respiratory complications – pneumonia - croup - otitis media GI complications-gastro enteritis -dehydration -malnutrition

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neurological complications – febrile convulsions -encephalitis Sub-acute sclerosing pan-encephalitis (virus enter into brain cause disorientation paralysis , and death) toxic encephalitis ophthalmic convulsions – conjunctivitis - corneal ulceration

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MANAGEMENT: Isolation

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Disinfection of nasal and throat secretions

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Q4H – TPR chart

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Tepid sponge

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Light and clean cloths

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Eye should washed with sterile water saline

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Antipyretics

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Attendants to use gown and mask

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Prophylactic antibiotics

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Should drink plenty of water and fruit juice Watch for complications Terminal disinfection of the room

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PREVENTION IMMUNIZATION

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ACTIVE IMMUNIZATION Live attenuated vaccine 2 groups – aerosolized vaccine - heat stable vaccine( single antigen) - MMR vaccine ( multiple antigens) PASSIVE IMMUNIZATION: Gamma globulin -0.25 to 0.5 ml/kg body wt -Give IM -Immunity lasts for 3 weeks

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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

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RUBELLA (GERMAN MEASLES)

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PROBLEM STATEMENT: 1964-65 when nearly , 12.5 million EPIDEMIOLOGICAL TRAID AGENT: Rubella virus HOST Humans ENVIRONMENT Late winter season

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CLINICAL FEATURES: PRODORMAL STAGE : Usually the symptoms are mild Fever Coryza (common cold) Sore throat Dry cough 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

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COMPLICATIONS: Arthritis Arthralgia Encephalitis Thrombocytopenic purpura Congenital malformation of foetus in a pregnant mother MODE OF TRANSMISSION: Droplet infection Trans-placental INCUBATION PERIOD: 15-20 days

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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

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DIAGNOSIS: Throat swab

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Serological investigation (1st sample drawn from 5days onset of illness and 2nd sample after 2 weeks later)

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ELISA Radio immune assay. CONGENITAL RUBELLA (RUBELLA SYNDROME)

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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.

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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%

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Cataract Deafness Damages of eyes, heart, ears jaundice Thrombocytospleenopathy LBW Pigmentary retinopathy Anemia Myocarditis Pneumonitis Hypospadiasis

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PREVENTION: ACTIVE IMMUNIZATION: 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

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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. .

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MUMPS

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PROBLEM STATEMENT : Acute infectious self limiting disease caused by RNA virus EPIDEMIOLOGICAL TRAID: AGENT: RNA virus.- belonging to myxovirus group HOST: Human beings Infective materials (salivary secretions of the reservoirs) Age Sexes Immunity (life long immunity)

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ENVIRONMENT: During winter season Over crowding 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

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CLINICAL FEATURES: Sudden onset of fever

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Associated with headache

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Body ache

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Malaise

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Associated with earache

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Lasting for 1 to 2 days followed by painful enlargement of one or both parotid gland Tenderness in the parotid gland

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Difficulty in opening the mouth Sublingual and sub- mandibular gland may also be affected

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COMPLICATIONS: Orchitis Oophoritis Myocarditis PREVENTION : Monovallent vaccine: -Live attenuated highly potent and effective to the tune of 90-95% -Dose – 0.5ml , SC (or) IM Combined vaccine: -MMR vaccine

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CONTROL: Control of mumps is difficult However the cases should be isolated and concurrent disinfection is carried out

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INFLUENZA

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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) -A (H2N2) -B viruses 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.

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EPIDEMIOLGICAL TRAID: AGENT: Orthomyxoviredae family 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 HOST: Age and sex (all ages and both sexes) Human mobility ENVIRONMENT: Season – winter season Overcrowding (eg.,) schools, instituitions, ships.etc.,

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MODE OF TRANSMISSION: Person to person by droplet infection or droplet nuclei Mainly through respiratory tract INCUBATION PERIOD: 18-72 hours PATHOGENISIS: Virus enters the respiratory tract Inflammation and necrosis of superficial epithelium of tracheal and bronchial mucosa Symptoms occur

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CLINICAL FEATURES: Fever Chills Aches and pains Coughing Generalised weakness Fever lasts from 1-5 days , averaging in 3 days in adults Frequent complications are acute sinusitis , otitis media Purulent bronchitis Pneumonia Rare complications:Reye’s syndrome (fatty liver with encephalopathy ) occur in children

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DIAGNOSTIC EVALUATION: VIRUS ISOLATION : Through nasopharyngeal secretions The virus can be detected by the indirect fluorescent antibody technique. After that Antigen analysis was done. SEROLOGY Haemagglutination inhibition (HI) ELISA

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PREVENTION: Good ventilation of public buildings

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Cover the face with handkerchief when coughing and sneezing

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Immunization

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Hygienic practices during handling of poultry products including hand washing and prevention of cross contamination

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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

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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

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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 .

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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

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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

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The virus could spread more rapidly , possibly reaching all continents in less than 3 months. PANDEMIC (H1N1) 2009 INFLUENZA PROBLEM STAEMENT: 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

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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. INCUBATION PERIOD: 2-3 days can range from up-to 7 days. CLINICAL FEATURES: UNCOMPLICATED INFLUENZA: Influenza like illness (ILI) : Fever Cough Sore throat

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Rhinorrhea Headache Muscle pain and malaise GI illness also present: Diarrhoea Vomiting mainly in children COMPLICATED INFLUENZA: Dyspnoea Tachypnea Hypoxia Pneumonia Encephalopathy

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Encephalitis Severe dehydration Renal failure Septic shock Other complications like, - Rhabdomylosis -Myocarditis asthma COPD Chronic hepatic and renal failure DM Other cardio vascular disease (chronic)

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SIGNS AND SYMPTOMS OF PROGRESSIVE DISEASE Uncomplicated influenza may progress to severe complicated pneumonia If progression occur urgent referral within 24 hours s/s of cardiopulmonary insufficiency : shortness of breath dyspnoea cyanosis bloody or coloured sputum chest pain <BP

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s/s with CNS complications altered mental status paralysis unconsciousness drowsiness seizures confusion invasive 2ry bacterial infection based on laboratory testing severe dehydration , manifested as decreased activity , dizziness , decreased UO and lethargy.

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RISK FACTORS FOR SEVERE DISEASE: Infants , young children in particular <2 years Pregnant women 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

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LABORETORY DIAGNOSIS: RT-PCR- reverse transcriptase chain reaction Respiratory samples combination of para-pharyngeal samples and throat swabs INFECTION CONTROL 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

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VACCINES: INACTIVATED VACCINE 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: Pregnant women Individuals with age more than 6 months Healthy adults and healthy children

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TREATMENT: Symptomatic treatment

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Anti viral drugs Antimicrobials

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O2 therapy

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Saturation monitoring

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Fluid replacement

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ANTIVIRAL THERAPY: OSELTAMIVIR Oseltamivir is indicated for treatment of influenza For adults –dose is -75mg /twice day for 5 days For infants >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

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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: 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.

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DIPTHERIA

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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.

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EPIDEMIOLOGICAL TRAID: AGENT: Corynebacterium depthreriae (klebs-loefflers bacillus) Human is the reservoir of infection HOST: Age (1-5 yrs) Sex ( both) Immunity ( breast-fed infants are immune ) ENVIRONMENTAL Winter season Indoor life and over crowding

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MODE OF TRANSMISSION: Droplet infection Direct contact Indirect contact ( contaminated fomites) Trans-placental animal milk PERIOD OF INFECTIVITY: 2-4 weeks INCUBTION PERIOD: 2-6 days occasionally longer

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PATHOGENISIS: The bacilli entered and passed through the tonsils , nasopharynx, or larynx and multiple Inflammatory reactions 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

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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

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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

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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.

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LARYNGEAL DIPTHERIA: Hoarseness of the voice Cough Dyspnoea Respiratory distress Restlessness Cyanosis Laryngeal stridor

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OTHER RARE FORMS OF DIPTHERIA’S ARE: Cutaneous diphtheria characterised by punched ulcer in the skin and absence of features of toxaemia Conjunctival diphtheria Gastro intestinal diphtheria Genital diphtheria Endocardiac diphtheria

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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 Treatment- 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

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Carriers: The carriers should be treated with 10 days course of oral erythromycin , which is most effective treatment of carriers CONTACTS: 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)

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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)

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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

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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 ANTISERA: Diptheria vaccine (prepared from horse serum)

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WHOOPING COUGH Chinese call it is a ‘hundred day cough’

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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%.

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EPIDEMILOGICAL TRAID: AGENT: B. pertussis B.parapertussis Certain viruses, adenovirus , parainfluenza virus HOST: 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

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ENVIRONMENT; Spring months Over crowding Poor socio economic status MODE OF TRANSMISSION: Droplet infection Fomites in the spread of infection appears to be very small , unless they are freshly contaminated INCUBATION PERIOD: Usually 7- 14 days, but not more than 3 weeks

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CLINICAL FEATURES 3 STAGES CATARRHAL STAGE Lasting about 10 days Insidious onset Lacrimation Sneezing and corynea Anorexia Malaise Hacking neck cough that becomes diurnal

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PAROXYSMAL STAGE: Lasting for 2-4 weeks Bursts of rapid ,Consecutive coughs followed by vomiting High pitched inspiration Vomiting 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

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COMPLICATIONS: It occur 5-6 % of cases , Chief complaints of pertussis are Bronchitis Bronchopneumonia Bronchioectesis Sub-conjunctival haemorrhage epistaxis Haemoptysis Cerebral haemorrhage which cause convulsions and coma

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CONTROL CASES Early diagnosis-bacteriological examination, fluorescent antibody technique Isolation Treatment- 30-50 mg /kg of body weight in 4 divided doses for 10 days (Ampicillin, Septran or tetracycline) CONTACTS: Prophylactic antibiotic (erythromycin or ampicillin) treatment for 10 days to prevent the infecting bacteria to become established.

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IMMUNIZATION: ACTIVE 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, Inconsolable screaming Seizures Hypotonic hypo-responsive episodes Anaphylactic shock Encephalopathy

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Contraindications: Anaphylactic reactions Encephalopathy Personal or strong family history of epilepsy Convulsions or similar CNS disorder PASSIVE IMMUNIZATION: Hyper-immune globulin in pertussis prophylaxis has yet to be established.

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MENINGOCOCCAL MENINGITIS

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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

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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

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EPIDEMIOLOGICAL TRAID: AGENT: N.meningitis is a gram negative diplococci Source of infection – nasopharynx of cases and carriers HOST: Age and sex – children and young adults of both sexes. Immunity - immunity is acquired by subclinical infection (mostly) ENVIRONMENTAL: Dry and cold months of the year Low socio economic groups living under poor housing conditions

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MODE OF TRANSMISSION: Droplet infection INCUBATION PERIOD: 3-4 days but may vary from 2-10 days SIGNS AND SYMPTOMS: Mainly asymptomatic Vomiting Photophobia Stiff neck Various neurological signs

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CONTROL CASES: Treatment with antibiotics Penicillin is the drug of choices Inj.penicillin – allergic patients , ceftriaxone and other 3rd generation cephalosporins should be substituted CARRIERS : Rifampicin are needed to eradicate the carrier state CONTACTS: Chemoprophylaxis suggested for close friends Rifampicin-600 mg twice a day for adults or minocycline-100 mg every 12 hours.

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MASS CHEMOPROPHYLAXIS: The other drugs are ciprofloxacin , minocycline , spiramycin and ceftriaxone. VACCINE: 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.

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ENVIRONMENTAL MEASURES: Improved housing and prevention of overcrowding are long –term measures

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SEVERE ACUTE RESPIRATORY INFECTIONS

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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. INCUBATION PERIOD: 2-7 days , commonly 3-5 days

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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

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DIAGNOSTIC TESTS REQUIRED FOR LABORATORY CONFIRMATION OF SARS: Conventional reverse transcriptase PCR (RT-PCR) Real-time reverse transcriptase PCR (real-time RT-PCR) for detecting viral RNA ELISA and immunoflurescent assay (IFA) COMPLICATIONS: Viral pneumonia Pulmonary decompensation Tension – pneumothorax Non-cardiogenic pulmonary oedema 20-30% of patients who having ARDS require intubation and mechanical ventilation

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TREATMENT: Severe case required intensive support Ribavirin (400-600 mg/day and 4g/day) Lopainavir/ritonavir (400mg/100mg) Interferone type-1 Intravenous immunoglobulin Systemic corticosteroids PROGNOSIS: Mortality rate is 14% 1% persons under 24 years of age >50% in persons over 65 years.

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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

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Simple hygienic measures such as hand washing after touching patients , use of appropriate and well fitted masks, are the introduction of infection control measures.

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Exit screening of international travellers Timely and accurate reporting and sharing of information with other authorities and/or governments .

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THANK YOU