BAUCHI STATE UNIVERSITY, GADAU

DEPARTENT OF PUBLIC HEALTH

LECTURE NOTE ON

DEFINITION, DESCRIPTION OF THE TRANSMISSION, PREVENTION AND

CONTROL OF COMMUNICABLE DISEASES

Learning Objectives At the end of this lesson, the student will be able to:
- Define communicable disease.
- Describe the factors involved in the chain of communicable disease transmission.
- Identify the different levels of disease prevention.
- Identify various phases of infectious disease
- Apply the different control methods of communicable diseases

1. Definition of communicable diseases

Communicable Diseases: These are illnesses due to specific infectious agents or its toxic
products, which arise through transmission of that agent, or its toxic products from an infected
person, animal or inanimate reservoir to a susceptible host, either directly or indirectly, through
an intermediate plant or animal host, vector or inanimate environment.

2. Chain of Disease Transmission

This refers to a logical sequence of factors or links of a chain that are essential to the
development of the infectious agent and propagation of disease.
The six factors involved in the chain of disease transmission are:
a. Infectious agent (etiology or causative agent)
b. Reservoir
c. Portal of exit
d. Mode of transmission
e. Portal of entry
f. Susceptible host
a. Infectious agent: An organism that is capable of producing infection or infectious disease. On
the basis of their size, etiological agents are generally classified into:
 Metazoa (multicellular organisms). (e.g. Helminths).

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  Protozoa (Unicellular organisms) (e.g. Ameobae)
 Bacteria (e.g. Treponema pallidum, Mycobacterium tuberculosis, etc.)
 Fungus (e.g. Candida albicans)
 Virus (e.g. Chickenpox, polio, etc.)
b. Reservoir of infection
Any person, animal, arthropod, plant, soil or substance (or combination of these) in which an
infectious agent normally lives and multiplies, on which it depends primarily for survival and
where it reproduces itself in such a manner that it can be transmitted to a susceptible host. Types
of reservoirs
1. Man: There are a number of important pathogens that are specifically adapted to man, such
as: measles, smallpox, typhoid, meningococcal meningitis, gonorrhea and syphilis. The cycle of
transmission is from human to human.
2. Animals: Some infective agents that affect man have their reservoir in animals. The term
“zoonosis” is applied to disease transmission from animals to man under natural conditions.
For example:
 Bovine tuberculosis cow to man
 Brucellosis - Cows, pigs and goats to man
 Anthrax - Cattle, sheep, goats, horses to man
 Rabies - Dogs, foxes and other wild animals to man
 Man is not an essential part (usual reservoir) of the life cycle of the agent

Animal ……. Animal…………Animal

↓
Human

3. Non-living things as reservoir: Many of the agents are basically saprophytes living in soil
and fully adapted to live freely in nature. Biologically, they are usually equipped to withstand
marked environmental changes in temperature and humidity. E.g.
 Clostridium botulinum etiologic agent of Botulism
 Clostridium tetani etiologic agent of Tetanus
 Clostridium welchi etiologic agent of gas gangrene
c. Portal of exit (mode of escape from the reservoir): This is the site through which the agent
escapes from the reservoir. Examples include:
 GIT: typhoid fever, bacillary dysentery, amoebic dysentery, cholera, ascariasis, etc
 Respiratory: tuberculosis, common cold, etc.
 Skin and mucus membranes: Syphilis

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d. Mode of transmission (mechanism of transmission of infection): Refers to the mechanisms
by which an infectious agent is transferred from one person to another or from a reservoir to a
new host. Transmission may be direct or indirect.
1. Direct transmission: Consists of essentially immediate transfer of infectious agents from an
infected host or reservoir to an appropriate portal of entry. This could be:
a. Direct Vertical
Such as: transplacental transmission of syphilis, HIV, etc.
b. Direct horizontal
Direct touching, biting, kissing, sexual intercourse, droplet spread onto the conjunctiva or onto
mucus membrane of eye, nose or mouth during sneezing coughing, spitting or talking; Usually
limited to a distance of about one meter or less.
2. Indirect transmission: Indirect contact through contaminated inanimate objects (fomites)
like:
 Bedding, toys, handkerchiefs, soiled clothes, cooking or eating utensils, surgical
instruments.
 Contaminated food and water
 Biological products like blood, serum, plasma or IV-fluids or any substance serving as
intermediate means by which an infectious agent is transported and introduced into a
susceptible host through a suitable portal of entry. The agent may or may not multiply or
develop in the vehicle before it is introduced into man.
b. Vector-borne transmission: Occurs when the infectious agent is conveyed by an arthropod
(insect) to a susceptible host.
1. Mechanical transmission: The arthropod transports the agent by soiling its feet or proboscis,
in which case multiplication of the agent in the vector does not occur. (e.g. common house fly.)
2. Biological transmission: This is when the agent multiplies in the arthropod before it is
transmitted, such as the transmission of malaria by mosquito.
C. Air-borne transmission: Dissemination of microbial agent by air to a suitable portal of entry,
usually the respiratory tract. Two types of particles are implicated in this kind of spread: dusts
and droplet nuclei.
Dust: Small infectious particles of widely varying size that may arise from soil, clothes, bedding
or contaminated floors and be resuspended by air currents.
Droplet nuclei: Small residues resulting from evaporation of fluid (droplets emitted by an
infected host). They usually remain suspended in the air for long periods of time.
e. Portal of entry: The site in which the infectious agent enters to the susceptible host. For
example:

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  Mucus membrane
 Skin
 Respiratory tract
 GIT
 Blood
f. Susceptible host (host factors): A person or animal lacking sufficient resistance to a particular
pathogenic agent to prevent disease if or when exposed. Occurrence of infection and its outcome
are in part determined by host factors. The term “immunity” is used to describe the ability of the
host to resist infection.
Resistance to infection is determined by non-specific and specific factors:
Non-specific factors
 Skin and mucus membrane
 Mucus, tears, gastric secretion
 Reflex responses such as coughing and sneezing
Specific factors
 Genetic-hemoglobin resistant to Plasmodium falciparum Naturally acquired or
artificially induced immunity.
Acquired immunity may be active or passive.
 Active immunity- acquired following actual infection or immunization.
 Passive immunity- pre-formed antibodies given to the host

Carrier and Its Type

A carrier is an infected person or animal who does not have apparent clinical disease but is a potential
source of infection to others.
a. Healthy or asymptomatic carriers: These are persons whose infection remains unapparent. For
example, in poliovirus, meningococcus and hepatitis virus infections, there is a high carrier rate.
b. Incubatory or precocious carriers: These are individuals or persons who excrete the pathogen
during the incubation period (i.e. before the onset of symptoms or before the characteristic features of the
disease are manifested). E.g. Measles, mumps, chickenpox and hepatitis.
c. Convalescent Carriers: These are those who continue to harbor the infective agent after recovering
from the illness. E.g. Diphtheria, Hepatitis B virus.
d. Chronic Carriers: The carrier state persists for a long period of time. E.g. Typhoid fever, Hepatitis B
virus infection

Phases of Communicable or Infectious Diseases

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 Incubation period: It is the interval of time between infection of the host and the first
appearance of symptoms and signs of the disease. Pathogen development but no clinical
manifestations
Prodromal period: It is the interval between the onset of symptoms of an infectious disease and
the appearance of characteristic manifestations. For example, in a measles patient, fever and
coryza occur in the first three days and Koplick spots in the buccal mucosa and characteristics
skin lesions appear on the fourth day
Period of Illness: This is the period in which disease most severe, characteristics sign and
symptoms of the illness developed and Immune response triggered
Convalescent period: This is of period in which the recover from the infection. All the sign and
symptom are declined.

Phase s of infectious diseases

Levels of Prevention
The different points in the progression of a disease at which one can intervene can be classified
according to three levels of prevention: primary, secondary, and tertiary.

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a Primary prevention: The objectives here are to promote health, prevent exposure, and
prevent disease.
Health promotion: This consists of general non-specific interventions that enhance health and
the body’s ability to resist disease, such as measures aimed at the improvement of socio-
economic status through the provision of adequately-paid jobs, education and vocational
training, affordable short it is any intervention that promotes a healthier and happier life. and
adequate housing, clothing, and food, old-age pension benefits; emotional and social support,
relief of stress, etc. In short it is any intervention that promotes a healthier and happier life
Prevention of exposure: - This includes actions such as the provision of safe and adequate
water, proper excreta disposal, vector control, safe environment at home (e.g., proper storage of
insecticides and medicines, out of children’s reach), at school and at work (e.g., proper
ventilation, monitoring of harmful substances in factories), and on the streets (e.g., driver
licensing laws)
Prevention of disease: -This occurs during the latency period between exposure and the
biological onset of disease. An example for this is immunization
Immunization against an infectious organism does not prevent it from invading the immunized
host, but prevents it from establishing an infection. Active immunization means exposing the
host to a specific antigen against which it will manufacture its own protective antibodies after an
interval of about three weeks (during which the immunized person remains susceptible to the
disease). Passive immunization means providing the host with the antibodies necessary to fight
against disease. Both forms of immunization act after exposure. However, for active
immunization to be protective, the timing of its administration must be at least three weeks prior
to exposure. Passive immunization, on the other hand, is commonly given after exposure has
occurred (as in the case of exposure to rabies or tetanus), or shortly before an exposure is
expected, as in the administration of immune globulin to prevent viral hepatitis A).
Breastfeeding is an example of an intervention that acts at all three levels of primary prevention:
ƒ Health promotion: by providing optimal nutrition for a young child, either as the sole diet up
to four months of age, or as a supplement in later months.
ƒ Prevention of exposure: by reducing exposure of the child to contaminated milk.
ƒ Prevention of disease after exposure: by the provision of anti-infective factors, including
antibodies, white blood cells, and others.
b. Secondary prevention: After the biological onset of disease, but before permanent damage
sets in, we speak of secondary prevention. The objective here is to stop or slow the progression
of disease so as to prevent or limit permanent damage, through the early detection and treatment
of disease. (e.g. breast cancer (prevention of the invasive stage of the disease), trachoma
(prevention of blindness), and syphilis (prevention of tertiary or congenital syphilis)).
c. Tertiary prevention: After permanent damage has set in, the objective of tertiary prevention is
to limit the impact of that damage. The impact can be physical, psychological, social (social

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stigma or avoidance by others), and financial. Rehabilitation refers to the retraining of remaining
functions for maximum effectiveness, and should be seen in a very broad sense, not simply
limited to the physical aspect. Thus, the provision of special disability pensions would be a form
of tertiary prevention.
Communicable Disease Control
This refers to the reduction of the incidence and prevalence of communicable disease to a level
where it cannot be a major public health problem.
Methods of Communicable Disease Control
There are three main methods of controlling communicable diseases:
1. Elimination of the Reservoir
a. Man as reservoir: When man is the reservoir, eradication of an infected host is not a viable
option. Instead, the following options are considered:
 Detection and adequate treatment of cases: arrests the communicability of the disease
(e.g. Treatment of active pulmonary tuberculosis).
 Isolation: separation of infected persons for a period of communicability of the disease.
Isolation is indicated for infectious disease with the following features: - High morbidity
and mortality - High infectivity
 Quarantine: limitation of the movement of apparently well person or animal who has
been exposed to the infectious disease for a duration of the maximum incubation period
of the disease.
b. Animals as reservoir: Action will be determined by the usefulness of the animals, how
intimately they are associated to man and the feasibility of protecting susceptible animals.
For example:
 Plague: The rat is regarded as a pest and the objective would be to destroy the rat
and exclude it from human habitation.
 Rabies: Pet dogs can be protected by vaccination but stray dogs are destroyed.
 Infected animals used for food are examined and destroyed.
c. Reservoir in non-living things: Possible to limit man’s exposure to the affected area (e.g.
Soil, water, forest, etc.).
2. Interruption of transmission This involves the control of the modes of transmission from the
reservoir to the potential new host through:
 Improvement of environmental sanitation and personal hygiene
 Control of vectors
 Disinfections and sterilization
3. Protection of susceptible host: This can be achieved through:

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  Immunization: Active or Passive
 Chemo-prophylaxis- (e.g. Malaria, meningococcal meningitis, etc.)
 Better nutrition
 Personal protection. (e.g. wearing of shoes, use of mosquito bed net, insect repellents,
etc.)

Example of communicable diseases

Water transmitted diseases
1. Typhoid fever
Definition A systemic infectious disease characterized by high continuous fever, malaise and
involvement of lymphoid tissues.
Infectious agent
Salmonella typhi
Salmonella enteritidis (rare cause)

Epidemiology

Occurrence- It occurs worldwide, particularly in poor socioeconomic areas. Annual incidence

is estimated at about 17 million cases with approximately 600,000 deaths worldwide. In
endemic areas the disease is most common in preschool and school aged children (5-19 years
of age).
Reservoir- Humans
Mode of transmission-
By water and food contaminated by feces and urine of patients and carriers. Flies may infect
foods in which the organisms then multiply to achieve an infective dose.
Incubation period –1-3 weeks
Period of communicability-
As long as the bacilli appear in excreta, usually from the first week throughout convalescence.
About 10% of untreated patients will discharge bacilli for 3 months after onset of symptoms,
and 2%-5% become chronic carriers.
Susceptibility and resistance-
Susceptibility is general and increased in individuals with gastric achlorhydria or those who
are HIV positive. Relative specific immunity follows recovery from clinical disease,
unapparent infection and active immunization but inadequate to protect against subsequent
ingestion of large numbers of organisms.

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 Clinical manifestation
First week- Mild illness characterized by fever rising stepwise (ladder type), anorexia,
lethargy, malaise and general aches. Dull and continuous frontal headache is prominent. Nose
bleeding, vague abdominal pain and constipation in 10% of patients.
Second week- Sustained temperature (fever). Severe illness with weakness, mental dullness or
delirium, abdominal discomfort and distension. Diarrhea is more common than first week and
feces may contain blood.
Third week- Patient continues to be febrile and increasingly exhausted. If no complications
occur, patient begins to improve and temperature decreases gradually.
Clinical manifestations suggestive of typhoid fever

 Fever- Sustained fever (ladder fashion)

 Rose spots- Small pallor, blanching, slightly raised macules usually seen on chest and
abdomen in the first week in 25% of white people.
 Relative bradycardia- Slower than would be expected from the level of temperature.
 Leucopoenia- White cell count is less than 4000/mm3 of blood.
Diagnosis
 Based on clinical grounds but this is confused with wide variety of diseases.
 Widal reaction against somatic and flagellar antigens.
 Blood, feces or urine culture.
Treatment
1. Ampicillin or co-trimoxazole for carriers and mild cases.
2. Chloramphenicol or ciprofloxacin or ceftriaxone for seriously ill patients.
Nursing care
1. Maintain body temperature to normal
2. . 2. Apply comfort measures.
3. 3. Follow side effects of drugs.
4. 4. Monitor vital signs.
5. 5. Follow strictly enteric precautions:
 wash hands
 wear gloves
 teach all persons about personal hygien
6. Observe the patient closely for sign and symptoms o
 bowel perforation ƒ erosion of intestinal ulcers
 sudden pain in the lower right side of the abdomen
 abdominal rigidity
 sudden fall of temperature and blood pressure

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 7. Accurately record intake and output.
8. Provide proper skin and mouth care.

Prevention and control

1. Treatment of patients and carriers
2. Education on handwashing, particularly food handlers, patients and childcare givers
3. Sanitary disposal of feces and control of flies.
4. Provision of safe and adequate water
5. Safe handling of food.
6. Exclusion of typhoid carriers and patients from handling of food and patients
7. Immunization for people at special risk (e.g. Travelers to endemic areas)
8. Regular check-up of food handlers in food and drinking establishments
2 Bacillary Dysentery (Shigellosis)
Definition
An acute bacterial disease involving the large and distal small intestine, caused by the
bacteria of the genus shigella.
Infectious agent
Shigella is comprised of four species or serotypes. Group A= Shigella dysentraie (most
common cause) Group B= Shigella flexneri Group C= Shigella boydii Group D= Shigella
sonnei
Epidemiology
Occurrence- It occurs worldwide, and is endemic in both tropical and temperate climates.
Outbreaks commonly occur under conditions of crowding and where personal hygiene is
poor, such as in jails, institutions for children, day care centers, mental hospitals and refugee
camps. It is estimated that the disease causes 600,000 deaths per year in the world. Two-
thirds of the cases, and most of the deaths, are in children under 10 years of age.
Reservoir- Humans
Mode of transmission- Mainly by direct or indirect fecal-oral transmission from a patient or
carrier. Transmission through water and milk may occur as a result of direct fecal
contamination. Flies can transfer organisms from latrines to a non-refrigerated food item in
which organisms can survive and
multiply.

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 Incubation period- 12 hours-4 days (usually 1-3 days)
Period of communicability- During acute infection and until the infectious agent is no
longer present in feces, usually within four weeks after illness.
Susceptibility and resistance- Susceptibility is general. The disease is more severe in young
children, the elderly and the malnourished. Breast-feeding is protective for infants and young
children.
Clinical Manifestation
􀂃 Fever, rapid pulse, vomiting and abdominal cramp are prominent.
􀂃 Diarrhea usually appears after 48 hours with dysentery supervening two days later.
􀂃 Generalized abdominal tenderness.
􀂃 Tenesmus is present and feces are bloody, mucoid and of small quantity.
􀂃 Dehydration is common and dangerous - it may cause muscular cramp, oliguria and shock.
Diagnosis
􀂃 Based on clinical grounds
􀂃 Stool microscopy (presence of pus cells)
􀂃 Stool culture confirms the diagnosis
Treatment
1. Fluid and electrolyte replacement
2. Co-trimoxazole in severe cases or Nalidixic acid in the case of resistance.
Prevention and control
1. Detection of carriers and treatment of the sick will interrupt an epidemic.
2. Handwashing after toilet and before handling or eating food.
3. Proper excreta disposal especially from patients, convalescent and carriers.
4. Adequate and safe water supply.
5. Control of flies.
6. Cleanliness in food handling and preparation.
3 Amoebiasis (Amoebic Dysentery)
Definition
An infection due to a protozoan parasite that causes intestinal or extra-intestinal disease.

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 Infectious agent
Entamoeba histolytica

Epidemiology
Occurrence- worldwide but most common in the tropics and sub-tropics. Prevalent in areas
with poor sanitation, in mental institutions and homosexuals. Invasive amoebiasis is mostly a
disease of young people (adults). Rare below 5 years of age, especially below 2 years.
Mode of transmission – Fecal-oral transmission by ingestion of food or water contaminated
by feces containing the cyst. Acute amoebic dysentery poses limited danger.
Incubation period- Variable from few days to several months or years; commonly 2-4
weeks.
Period of communicability- During the period of passing cysts of E. histolytica, which may
continue for years.
Susceptibility and resistance- Susceptibility is general.
Susceptibility to reinfection has been demonstrated but is
apparently rare.
Clinical Manifestation
􀂃 Starts with a prodormal episode of diarrhea, abdominal cramps, nausea, vomiting and
tenesmus.
􀂃 with dysentery, feces are generally watery, containing mucus and blood.
Diagnosis
􀂃 Demonstration of etamoeba histolytica cyst or trophozoite in stool.
Treatment
1. Metronidazole or Tinidazole
Prevention and control
1. Adequate treatment of cases
2. Provision of safe drinking water
3. Proper disposal of human excreta (feces) and handwashing following defecation.
4. Cleaning and cooking of local foods (e.g. raw vegetables) to avoid eating food
contaminated with feces.
4. Cholera

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Definition
An acute illness caused by an enterotoxin elaborated by vibrio cholerae.

Infectious agent
Vibrio cholerae
Epidemiology
Occurrence- has made periodic outbreaks in different parts of the world and given rise to
pandemics. Endemic predominantly in children.
Reservoir- Humans
Mode of transmission- by ingestion of food or water directly or indirectly contaminated with
feces or vomitus of infected person.
Incubation period- from a few hours to 5 days, usually 2-3 days.
Period of communicability- for the duration of the stool positive stage, usually only a few days
after recovery. Antibiotics shorten the period of communicability.
Susceptibility and resistance- Variable. Gastric achlorhydria increases risk of illness. Breast-fed
infants are protected.
Clinical Manifestation
􀂃 Abrupt painless watery diarrhea; the diarrhea looks like rice water.
􀂃 In severe cases, several liters of liquid may be lost in few hours leading to shock.
􀂃 Severely ill patients are cyanotic, have sunken eyes and cheeks, scaphoid abdomen, poor skin
turgor, and thread or absent pulse.
􀂃 Loss of fluid continues for 1-7 days.
Diagnosis
􀂃 Based on clinical grounds
􀂃 Culture (stool) confirmation
Treatment
1. Prompt replacement of fluids and electrolytes
􀂃 Rapid IV infusions of large amounts
􀂃 Isotonic saline solutions alternating with isotonic sodium bicarbonate or sodium lactate.

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2. Antibiotics like tetracycline dramatically reduce the duration and volume of diarrhea resulting
in early eradication of vibrio cholerae.

Nursing care
1. Wear gown and glove.
2. Wash your hands.
Monitor output including stool output.
4. Protect the patient family by administering Tetracycline.
5. Health education.
Prevention and control
1. Case treatment
2. Safe disposal of human excreta and control of flies
3. Safe public water supply
4. Handwashing and sanitary handling of food
5. Control and management of contact cases

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 AIR-BORNE DISEASES
Introduction
The organisms causing the diseases in the air-borne group enter the body via the respiratory tract.
When a patient or carrier of pathogens talks, coughs, laughs, or sneezes, he/she discharges fluid
droplets. The smallest of these remain up in the air for some time and may be inhaled by a new
host. Droplets with a size of 1-5 microns are quite easily drawn in to the lungs and retained there.
Droplets that are bigger in size will not remain air-borne for long but will fall to the ground.
Here, however, they dry and mix with dust. When they contain pathogens that are able to survive
drying, these may become air-borne again by wind or something stirring up the dust, and they
can then be inhaled. Air-borne diseases, obviously, will spread more easily when there is
overcrowding, as in overcrowded class rooms, public transport, canteens, dance halls, and
cinemas. Good ventilation can do much to counteract the effects of overcrowding. Air-borne
diseases are mostly acquired through the respiratory tract.
1.Measles (Rubella)
Definition
An acute highly communicable viral disease
Infectious agent
Measles virus
Epidemiology
Occurrence- Prior to widespread immunization, measles was common in childhood so that more
than 90% of people had been infected by age 20; few went through life without any attack.
Reservoir- Humans
Mode of transmission- Airborne by droplet spread, direct contact with nasal or throat secretions
of infected persons and less commonly by articles freshly solid with nose and throat secretion.
Greater than 94% herd immunity may be needed to interrupt community transmission.
Incubation period- 7-18 days from exposure to onset of fever.
Period of communicability- slightly before the prodromal period to four days after the
appearance of the rash and minimal after the second day of rash.
Susceptibility and resistance- All those who are nonvaccinated or have not had the disease are
susceptible. Permanent immunity is acquired after natural infection or immunization.
Clinical Manifestation
􀂃 Prodromal fever, conjunctivitis, coryza, cough and Koplik spots on the buccal mucosa
􀂃 A characteristic red blotchy rash appears on the third to seventh day, beginning on the face,
gradually becoming generalized, lasting 4-7 days.

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􀂃 Leucopoenia is common.
􀂃 Complications like otitis media, pneumonia, diarrhea, encephalitis, croup (Laryngo tracheo
bronchitis) may result from viral replication or bacterial super infection.
Diagnosis
􀂃 Based on clinical and epidemiological grounds
Treatment
1. No specific treatment
2. Treatment of complications
3. Vitamin A provision
Nursing care
1. Advise patient to have bed rest.
2. Relief of fever.
3. Provision of non-irritant small frequent diet.
4. Shorten the fingernails.
Prevention and control
1. Educate the public about measles immunization Immunization of all children (less than 5
years of age) who had contact with infected children.
3. Provision of measles vaccine at nine months of age.
4. Initiate measles vaccination at 6 months of age during epidemic and repeat at 9 months of age.

2. Diphtheria
Definition
An acute bacterial disease involving primarily tonsils, pharynx, nose, occasionally other mucus
membranes or skin and sometimes the conjunctiva or genitalia.
Infectious agent
Corynebacterium diphtheriae
Epidemiology

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Occurrence- Disease of colder months in temperate zones, involving primarily non-immunized
children under 15 years of age. It is often found among adult population groups whose
immunization was neglected. Unapparent, cutaneous and wound diphtheria cases are much more
common in the tropics.
Reservoir- Humans
Mode of transmission- contact with a patient of carrier. i.e. with oral or nasal secretions or
infected skin.
Incubation period- usually 2-5 days
Period of communicability- variable, until virulent bacilli have disappeared from discharges
and lesion; usually 2 weeks or less.
Susceptibility and resistance- Susceptibility is universal. Infants borne to immune mothers are
relatively immune, but protection is passive and usually lost before 6 months. Recovery from
clinical disease is not always followed by lasting immunity. Immunity is often acquired through
unapparent infection. Prolonged active immunity can be induced by diphtheria toxoid.
Clinical Manifestation
􀂃 Characteristic lesion marked by a patch or patches of an adherent grayish membrane with a
surrounding inflammation (pseudo membrane).
􀂃 Throat is moderately sore in pharyngo tonsillar diphtheria, with cervical lymph nodes
somewhat enlarged and tender; in severe cases, there is marked swelling and edema of neck.
􀂃 Late effects of absorption of toxin appearing after 2-6 weeks, including cranial and peripheral,
motor and sensory nerve palsies and myocarditis (which may occur early) and are often severe.
Diagnosis
􀂃 Based on clinical and epidemiological grounds
􀂃 Bacteriologic examination of discharges from lesions.

Treatment
1. Diphtheria antitoxin
2. Erythromycin for 2 weeks but 1 week for cutaneous form or
3. Procaine penicillin for 14 days or single dose of Benzathin penicillin Primary goal of
antibiotic therapy for patients or carriers is to eradicate C. diphtheriae and prevent transmission
from the patient to susceptible contacts.
Prevention and control

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1. Educate the public, and particularly the parents of young children, of the hazards of diphtheria
and the necessity for active immunization.
2. Immunization of infants with diphtheria toxoid.
3. Concurrent and terminal disinfection of articles in contact with patient and soiled by
discharges of patient.
4. Single dose of penicillin (IM) or 7-10 days course of Erythromycin (PO) is recommended for
all persons exposed to diphtheria.
3. Pertusis (whooping cough)
Definition
An acute bacterial disease involving the respiratory tract.
Infectious agent
Bordetella pertusis
Epidemiology
Occurrence- An endemic disease common to children especially young children everywhere in
the world. A marked decline has occurred in incidence and mortality rates during the past four
decades. Outbreaks occur periodically. Endemic in developing world and 90% of attacks occur in
children under 6 yearsof age.
Reservoir- Humans
Mode of transmission- Primarily by direct contact with discharges from respiratory mucus
membranes of infected persons by airborne route, probably by droplets. Indirectly by handling
objects freshly solid with nasopharyngeal secretions.
Incubation period- 1-3 weeks
Period of communicability- Highly communicable in early catarrhal stage before the
paroxysmal cough stage. The most contagious disease with an attack rate of 75-90%. Gradually
decreases and becomes negligible in about 3 weeks. When treated with erythromycin,
infectiousness is usually 5 days or less after onset of therapy.
Susceptibility and resistance- Susceptibility to nonimmunized individuals is universal. One
attack usually confers prolonged immunity but may not be lifelong.
Clinical manifestation
The disease has insidious onset and 3 phases:
1. Catarrhal phase
􀂃 Lasts 1-2 weeks

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􀂃 Cough and rhinorrhea
2. Paroxysmal phase
􀂃 Explosive, repetitive and prolonged cough
􀂃 Child usually vomits at the end of paroxysm
􀂃 Expulsion of clear tenacious mucus often followed by vomiting
􀂃 Whoop (inspiratory whoop against closed glottis) between paroxysms.
􀂃 Child looks healthy between paroxysms
􀂃 Paroxysm of cough interferes with nutrition and cough
􀂃 Cyanosis and sub conjunctiva hemorrhage due to violent cough.
3. Convalescent phase
􀂃 the cough may diminish slowly or may last long time.
􀂃 After improvement the disease may recur.
Diagnosis
􀂃 Difficult to distinguish it from other URTI
􀂃 History and physical examination at phase two
(paroxysmal phase) ensure the diagnosis.
􀂃 Marked lymphocytosis.
Treatment
1. Erythromycin- to treat the infection in phase one but to decrease transmission in phase two
2. Antibiotics for super infections like pneumonia because of bacterial invasion due to damage to
cilia.
Nursing care
1. Proper feeding of the child.
2. Encourage breastfeeding immediately after an attack (each paroxysm).
3. Proper ventilation- continuous well humidified oxygen administration.
4. Reassurance of the mother (care giver),
Prevention and control
1. Educate the public about the dangers of whooping cough and the advantages of initiating
immunization at 6 weeks of age.

19
2. Consider protection of health workers at high risk of exposure by using erythromycin for 14
days.
4 Tuberculosis
Definition
A chronic and infectious mycobacterial disease important as a major cause of illness and death in
many parts of the world.
Infectious agent.
Mycobacterium tuberculosis- human tubercle bacilli (commonest cause) Mycobacterium bovis-
cattle and man infection Mycobacterium avium- infection in birds and man.
Epidemiology
Occurrence- Worldwide, however underdeveloped areas are more affected. Affects all ages and
both sexes. Age groups between 15-45 years are mainly affected. According to the WHO 1995
report, 9 million cases and 3 million deaths have occurred. According to the Ministry of Health
report in 1993 E.C, tuberculosis was a leading cause of outpatient morbidity (ranked 8th with
2.2%), leading cause of hospitalization (ranked 3rd with 7.8%) and leading cause of hospital
death (ranked 1st with 10.1%). Tuberculosis has two major clinical forms. Pulmonary (80%)
primarily occurs during childhood and secondarily 15-45 years or later. The other is extra
pulmonary, which affects all parts of the body. Most common sites are lymph nodes, pleura,
Genitourinary tract, bone and joints, meninges and peritoneum.
Mode of transmission- Through aerosolized droplets mainly from persons with active ulcerative
lesion of lung expelled during talking, sneezing, singing, or coughing directly. Untreated
pulmonary tuberculosis positive (PTB+) cases are the source of infection. Most important is the
length of time of contact an individual shares volume of air with an infectious case. That is
intimate, prolonged or frequent contact is required. Transmission through contaminated fomites
(clothes, personal articles) is rare. Ingestion of unpasteurized milk transmits bovine tuberculosis.
Overcrowding and poor housing conditions favor the disease transmission.
Incubation period- 4-12 weeks
Period of communicability- as far as the bacilli is present in the sputum
Susceptibility and resistance- under 3 years old children, adolescents, young adults, the very
old and the immunosuppressed are susceptible. Everyone who is non-infected or non-vaccinated
can be infected. HIV is an important risk factor for the development of HIV associated
tuberculosis by facilitating:
􀂃 Reactivation or
􀂃 Progression of recent infection or
􀂃 Reinfection

20
Clinical Manifestation
Pulmonary tuberculosis
􀂃 Persistent cough for 3 weeks or more
􀂃 Productive cough with or without blood-stained sputum
􀂃 Shortness of breath and chest pain
􀂃 Intermittent fevers, night sweats, loss of weight, loss of appetite, fatigue and malaise.
TB lymph adenitis
􀂃 Slowly developing and painless enlargement of lymph
nodes followed by matting and drainage of pus.
Tuberculosis pleurisy
􀂃 Pain while breathing in, dull lower chest pain, slight
cough, breathlessness on exertion.
TB of bones and joints
􀂃 Localized pain and/or swelling, discharging of pus, muscle weakness, paralysis and stiffness
of joints.
Intestinal TB
􀂃 Loss of weight and appetite
􀂃 Abdominal pain, diarrhea and constipation
􀂃 Mass in the abdomen
􀂃 Fluid in the abdominal cavity (ascites)
Tuberculos meningitis
􀂃 Headache, fever, vomiting, neck stiffness and mental confusion of insidious onset.

Diagnosis
1. Clinical manifestations
2. Sputum smears for acid-fast bacilli (AFB), which is the Golden standard. However, one
positive result does not justify starting anti TB treatment since errors can never be excluded.
3. Acid-fast stain for AFB can be done for extra pulmonary tuberculosis having pus-y discharge.

21
4. Radiological examination: This is unreliable because it can be caused by a variety of
conditions or previous TB patients who are healed may have chest x-ray giving the appearance of
active TB, which requires treatment.
5. Histopathological examination: Biopsies forextrapulmonary TB (e.g. Tuberculos
lymphadenitis)
6. Tuberculin test (mantoux): Helpful in non-BCG vaccinated children under 6 years of age
7. Culture: Complex and sophisticated tool, which takes several weeks to yield results. Not a
primary diagnostic tool in our country.
Treatment
The following drugs are being used for treatment of TB in Ethiopia.
􀂃 Streptomycin (s) daily IM injection
􀂃 Ethambutol(E)
􀂃 Rifampin (R)
􀂃 Thiacetazone (T)
􀂃 Isoniazid (H)
􀂃 Pyrazinamide (Z)
All drugs, except streptomycin, which is administered daily
through in route) are to be taken orally as a single daily dose
preferably on an empty stomach.
Drug regimens (prescribed course of therapy)
1) Short course chemotherapy regimen
􀂃 (DOTS) intensive phase- S(RH)Z for two months
􀂃 Continuation phase- TH (EH) for the next 6 months.
2) Long course chemotherapy regimen.
􀂃 Intensive phase- S(TH)or S(EH) for 2 months
􀂃 Continuation phase-TH or EH for the next 10 months
Nursing care
1. Educate the patient how and when to take the prescribed medication.
2. Tell the patient not to stop the medication unless he/she is told to do so.
3. Tell the patient to come to the health institution if he/she develops drug side effects.

22
4. Advice the patient on the importance of taking adequate and balanced diet and to eat what is
available at home.
Prevention and control
1. Chemotherapy of cases
2. Chemoprophylaxis for contacts INH (Isoniazid) for adults and children who have close contact
with the source of infection
3. Immunization of infants with BCG
4. Educate patients with TB about the mode of disease transmission and how to dispose their
sputum and cover their mouth while coughing, sneezing, etc.
5. Public health education about the modes of disease transmission and methods of control
􀂃 Improved standard of living
􀂃 Adequate nutrition
􀂃 Health housing
􀂃 Environmental sanitation
􀂃 Personal hygiene; etc.
􀂃 Active case finding and treatment

23
 ARTHROPOD OR INTERMEDIATE
VECTOR-BORNE DISEASES
Introduction
Generally speaking a vector is any carrier of disease, but in the case of the ‘vector-borne
diseases’ we restrict the word to those invertebrate hosts (insects or snails), which are an
essential part of the life cycle of the disease organism. A housefly just carrying bacteria or
amoebic cysts on its feet to food is not regarded as a vector: this would be simple mechanical
spread. Insect vectors usually acquire the disease organism by sucking blood from infected
persons, and pass it on, later, by the same route. There are other routes, however; infection may
enter skin cracks or abrasions either from infected feces deposited when feeding, or from body
fluid when an insect is crushed. By definition the disease organism undergoes a period of
development inside the vector, and the time taken for this is called the extrinsic incubation
period.
Mosquito-Borne Diseases
1. Malaria
Definition
An acute infection of the blood caused by protozoa of the genus plasmodium.
Infectious agent.
􀂃 Plasmodium falciparum/malignant tertian: Invades all ages of red blood cells. Red blood cell
cycle is 48 hours
􀂃 Plasmodium vivax/benign tertian: Invades reticulocytes only. Red blood cell cycle is 48 hours.
􀂃 Plamodium ovale/tertian: Invades reticulocytes only. Red blood cell cycle is 48 hours.
􀂃 Plasmodium Malariae/Quartan malaria: Invades reticulocytes only. Red blood cell cycle is 72
hours.

Epidemiology
Occurrence- Endemic in tropical and sub-tropical countries of the world. Affects 40% of the
world population. Children less 5 years of age, pregnant women and travelers to endemic areas
are risk groups. Plasmodium falciparum 60% and vivax 40% are common in Ethiopia.
Predisposing factors are:
􀂃 Environment- physical environment for the propagation
􀂃 Patient source
􀂃 Susceptible recipients

24
􀂃 Anopheles capable to transmit the parasite
􀂃 Socio-economic factors like immigration, war, poverty, ignorance, agricultural irrigation
farms, etc.
Reservoir- Humans
Mode of transmission- By the bite of an infective female anopheles mosquito, which sucks
blood for egg maturation. Blood transfusion, hypodermic needles, organ transplantation and
mother to fetus transmission is possible. Since there is no pre-erythrocytic (tissue) cycle, the
incubation period is short. Anopheles gambae and funestus are common vectors.
Incubation period- Varies with species
􀂃 Plasmodium falciparum 7-14 days
􀂃 Plasmodium virvax 8-14 days
􀂃 Plasmodium ovale 8-14 days
􀂃 Plasmodium malariae 7-30 days
Period of communicability- Mosquitoes are infective as long as infective gametocytes are
present in the blood of patients. Once infected, mosquito remains infective for life.
Susceptibility and resistance- Susceptibility is universal except in some host-resistance factors:
Nonspecific factors
􀂃 Increased splenic clearance reaction
􀂃 Hyperpyrexia- which is said to be schizontcidal
􀂃 Sickle cell traits are resistant to plasmodium falciparum Duffy blood group deficiency (Duffy
antigen negative red blood cells) lack receptor for plasmodium vivax.
􀂃 Because of passive immunity infants are resistant in early life.

Specific factors
This is a humoral and cell mediated immunity that is species and strain specific, and hard-won
after repeated infection.
Clinical Manifestation
Chills, rigor, fever, head ache, diarrhea, hallucinations, abdominal pain, aches, renal or
respiratory symptoms, jaundice, etc.
Diagnosis
􀂃 Clinical manifestation and epidemiological grounds

25
􀂃 Blood film for hemoparasite
􀂃 White blood cell count
􀂃 Blood culture to rule out sepsis
􀂃 Chest X-ray to rule out pneumonia.
Treatment
1. Plasmodium vivax, ovale and sensitive plasmodium falciparum
􀂃 Chloroquine or
􀂃 Fansidar
2. Chloroquine resistant falciparum and when sensitivity
pattern is not known.
􀂃 Quinine or
􀂃 Fansidar
Nursing care
1. Advise patient to come back if the illness gets severe.
2. Advise on personal protection (bed nets, etc).
3. Reduce fever and maintain comfort.
Prevention and control
1. Chemoprophylaxis- for those who go to endemic areas but not for those who live in the
endemic area (travelers and newcomers); for under-five children and pregnant mothers who have
not enough immunity.
2. Vector control
􀂃 Avoiding mosquito breeding sites
􀂃 Residual DDT spray or other chemicals
􀂃 Personal protection against mosquito bite (use of bed nets, etc.)
3. Chemotherapy of cases
2. Yellow fever
Definition
An acute infectious viral disease of short duration and varying severity.
Infectious agent

26
Yellow fever virus
Epidemiology
Occurrence- The disease exists in two transmission cycles. Namely, the sylvatic or Jungle cycle,
which occurs between mosquitoes and non-human primates, and an urban cycle, involving Aedes
aegypti mosquitoes and humans. Found in southwest Ethiopia (Gambella region).
Reservoir- Urban areas- humans and Aedes aegypti mosquitoes. Forest areas- Vertebrates other
than humans (mainly monkeys) and forest mosquitoes.
Mode of transmission- By the bite of infective Aedes aegypti mosquitoes
Incubation period- 3-6 days
Period of communicability- Blood of patients is infective for mosquitoes shortly before onset of
fever and for the first 3-5 days of illness. Not communicable by contact or common vehicles. The
disease is highly communicable where many susceptible people and abundant vector mosquitoes
co-exist.
Susceptibility and resistance- Recovery from yellow fever is followed by lasting immunity;
second attacks are unknown. Transient passive immunity in infants born to immune mothers may
persist for up to 6 months. In natural infections, antibodies appear in the blood within the first
week.
Clinical Manifestation
􀂃 Typical attacks are characterized by sudden onset of fever, chills, headache, backache,
generalized pain, prostration, nausea and vomiting.
􀂃 Slow and weak pulse.
􀂃 Bleeding tendency is common resulting in epistaxis, bleeding of gums, hematemesis, melaena.
􀂃 Jaundice occurs due to liver cell necrosis and this may result in liver failure and death.
􀂃 Albumin uria occurs due to nephrosis and this may result in kidney failure and anuria.
􀂃 Patients surviving the seventh day of the disease usually recover.
Diagnosis
􀂃 History of residence and/or travel to endemic area
􀂃 Clinical manifestation
Treatment
􀂃 No specific treatment.
Nursing care
1. Monitor vital signs regularly.

27
2. Maintain body temperature to normal.
3. Monitor input and output balance.
4. Keep patient in screened rooms or under mosquito nets to avoid further infection.
Prevention and control
1. Active immunization of all people greater than 9 months of age necessarily exposed to
infection because of residence, occupation or travel.
2. Eradication or control of Aedes aegypti mosquitoes in urban areas.
3. Sylvatic /Jungle yellow fever- immunization to all people in rural communities whose
occupation brings them into forests in yellow fever areas and for people who visit those areas.
4. Notification of the disease to the concerned health authorities.
3. Plague
Definition
A highly infectious bacterial disease which can kill many people within a short time.
Infectious agent
Yersinia pestis, the plague bacillus.
Epidemiology
Occurrence- Endemic in wild rodents living in forests in the highlands. Wild rodent plague
exists in western USA, large areas of South America, North, Central, Eastern and Southern
Africa, Central and Southeast Asia. However, urban plague is controlled in most of the world.
Reservoir- Wild rodents (especially ground squirrels) are the natural vertebrate reservoir of
plague. Wild carnivores and domestic cats may also be a source of infection to people.
Mode of transmission- Through the bite of infected fleas. Handling of tissues of infected
animals.
Incubation period- 1-7 days.
Period of communicability- Fleas may remain infective for months under suitable conditions of
temperature and humidity. Bubonic plague is not usually transmitted directly from person to
person unless there is contact with pus from suppurating buboes. Pneumonic plague may be
highly communicable under appropriate climatic conditions. Overcrowding facilitates
transmission.
Susceptibility and resistance- Susceptibility is general. Immunity after recovery is relative; it
may not protect against a large inoculum.
Clinical Manifestation

28
Bubonic plague- Characterized by swelling of lymph glands (bubos); mostly the glands of the
groins, sometimes arm pit or other places. Swelling may be the size of an egg, tender or non-
tender. Other symptoms are:
􀂃 Sudden high fever
􀂃 Shock
􀂃 Prostration
􀂃 Coma
􀂃 Death within 3-5 days
Pneumonic plague
􀂃 Acute onset
􀂃 Severe prostration
􀂃 Watery sputum quickly followed by blood-stained sputum.
􀂃 Pleural effusion
􀂃 Death within 1-2 days
Diagnosis
􀂃 Gram stain of sputum or pus-gram negative bacilli.
Treatment
1. Early treatment with antibiotics like streptomycin or tetracycline or sulfa groups.
Prevention and Control
1. Chemotherapy of patient
2. Chemoprophylaxis of all contacts with Sulfa drugs
3. The area where disease occurs must be quarantined (isolated from outer world)
4. Insecticides to kill fleas
5. Encourage people to kill rats
6. Notify the disease to the concerned health authority.
4. Endemic Typhus (Flea-borne typhus)
Definition
A rickettsial disease whose course resembles that of louseborne typhus, but is milder.
Infectious agent

29
Rickettsia typhi (Rickettsia mooseri)
Epidemiology
Occurrence- Worldwide, found in areas where people and rats occupy the same buildings and
where large numbers of mice live. Occurs sporadically.
Reservoir-Rats, mice and possibly other small animals. Infection is maintained in nature by a
rat-flea-rat cycle where rats are reservoirs (Commonly rattus and rattus novergicus).
Mode of Transmission- Infective rat fleas defecate rickettsia while sucking blood,
contaminating the bite site and other fresh skin wounds. An occasional case may follow
inhalation of dried infective flea feces.
Incubation period- from 1 to 2 weeks; commonly 12 days
Period of communicability- Not directly transmitted from person to person. Once infected, fleas
remain so for life.
Susceptibility and resistance- Susceptibility is general. One attack confers immunity.
Clinical Manifestation
􀂃 Prodromal symptoms of headache, myalgia, arthralgia, nausea, and malaise developing 1 to 3
days before the abrupt onset of chills and fever. Nearly all patients experience nausea and
vomiting early in the illness.
􀂃 The duration of untreated illness averages 12 days.
􀂃 Rash is present in only 13% of patients
􀂃 Pulmonary involvement: non-productive cough and pneumonia.
Diagnosis
􀂃 Epidemiological ground
􀂃 Weilfelix agglutination test (Serology)
Treatment
1. Doxycyclin or
2. Chloramphenicol
Prevention and control
1. Destroy rats from burrows and harborages.
2. Use insecticides to abolish flea from livingquarters.
3. Treatment of patients.

30
 SEXUALLY TRANSMITTED
DISEASES
Introduction
The diseases belonging to this group are usually transmitted during sexual intercourse; hence the
name sexually transmitted diseases or STDs. During sexual intercourse there is close body
contact, which is an ideal situation for transmission. The causative organisms of the STDs are
very easily killed by drying or by cooling to below body temperature. Therefore, transmission of
these agents from one person to another can only occur under very special circumstances, mostly
during sexual intercourse. STDs are very common in adults, but they are often hidden for fear of
the opinion of others. Single young men are a high–risk group for STDs, as they satisfy their
sexual needs with women who have many sexual partners (promiscuity). They may be
professional prostitutes, barmaids, or persons who in other ways gain from casual sexual
relationships. This group is called the promiscuous women pool (PWP). They are the reservoir of
STDs.
Risk factors are:
1. Age: 15 years and older
2. Marital status: unmarried people who often change their sexual partners are more frequently
exposed. Most of the women in the PWP are unmarried or divorced.
3. Occupation: soldiers, policemen, students, seasonal laborers, and other people who are
temporarily away from home tend to expose themselves more easily.
4. Residence: Due to industrialization and consequent urbanization there is usually a large group
of single young men in towns. Women in towns may have more difficulty in earning their daily
living than women in rural areas and may take up prostitution for money.
5. Promiscuity

1. Syphilis (Hard chancre)

Definition
A disease characterized by a primary lesion, a later secondary eruption on the skin and mucus
membranes, then a long period of latency, and finally late lesions of skin, bones, viscera, CNS
and cardiovascular systems.
Infectious agent
Treponema pallidum, a spirochete.
Epidemiology

31
Occurrence: Worldwide spread. Primarily involving sexually active young people between 20
and 29 years. More common in urban than rural areas.
Reservoir - Humans
Mode of transmission: - by direct contact with lesion mainly during sexual intercourse.
Accidentally by touching infective tissues. Or via blood transfusion. Or congenitally, which may
occur before birth, in the case of an infected mother.
Incubation period– 10 days to 3 months, usually 3 weeks.
Period of communicability – variable and indefinite, during primary and secondary stages and
also in mucocutaneous recurrences that may occur during the first 4 years of latency. Extent of
communicability through sexual activity during this latent period is not established. Adequate
penicillin treatment usually ends infectivity within 24 – 48 hours.
Susceptibility and resistance – Susceptibility is universal, although only approximately 30% of
exposures result in infection. Infection leads to developing immunity against T. pallidum
gradually and to some extent, but immunity usually fails to develop because of early treatment in
the primary and secondary stages.
Clinical Manifestation
The clinical presentation is divided into three groups:
a) Primary syphilis – consists of hard chancre, the primary lesion of syphilis, together with
regional lymphadenitis. The hard chancre is a single, painless ulcer on the genitalia or
elsewhere (lips, tongue, breasts) and heals spontaneously in a few weeks without
treatment. The lymph glands are bilaterally enlarged and not painful. There will not be
suppuration. Secondary syphilis - After 4 – 6 weeks of the primary
b) infection, a generalized secondary eruption appears, often
c) accompanied by mild constitutional symptoms. These
d) early rashes tend to be symmetrical, quickly passing, and
e) do not itch. These early skin lesions are highly infective
f) and many spirochetes are demonstrated in them.
g) c) Tertiary syphilis -This stage is characterized by
h) destructive, non-infectious lesions of the skin, bones,
i) viscera, and mucosal surfaces. Other disabling
j) manifestations occur in the cardiovascular system (aortic
k) incompetence, aneurysms) or central nervous system
l) (dementia paralytica, tabes dorsalis).
m) d) Syphilis in pregnancy- According to the severity,
n) congenital syphilis can result in congenital abnormalities,
o) still birth, or repeated spontaneous abortions.
p) Diagnosis
q) 􀂃 Serological test – will be positive 6 to 8 weeks after
r) infection

32
s) 􀂃 Dark field microscopy of smears from primary lesion
t) (hard chancre) or from skin lesions in the early secondary
u) stage will show the spirochaetes.
Treatment
1. Primary and secondary syphilis
􀂃 Benzathin penicillin 2.4 M IU Im stat or
􀂃 Tetracycline or Erythromycin 500mg PO Qid for 2 weeks for penicillin sensitive people
2. Tertiary syphilis
􀂃 Benzathin penicillin 2.4 M IU Im single dose every week for 3 consecutive weeks or
􀂃 Tetracycline or Erythromycin for one month for penicillin sensitive individuals.
3. Early congenital syphilis
􀂃 Crystalline penicillin 50,000 IU/ Kg per dose IV or Im bid in the first 7 days of life and
Tid then after for 10- 14 days.
Prevention and control
1. Treatment of cases
2. Treatment of contacts and source of infection
3. Health education on safe sex
4. Controlling STDs among commercial sex workers
􀂃 Monthly check up and treatment of cases
􀂃 Provision of condom
5. Screening of pregnant women and early treatment to prevent congenital syphilis
6. Screening of blood before transfusion.
2. Candidiasis
Definition
A mycosis usually confined to the superficial layers of skin or mucus membranes, presenting
clinically as oral thrush or vulvovaginitis.
Infectious agent
Candida albicans (most common cause)
Candida tropicalis (rare cause)
Epidemiology

33
Occurrence – Worldwide. Candida albicans is often part of the normal human flora.
Reservoirs – Humans
Mode of transmission – contact with secretions or excretions of mouth, skin, vagina and
feces, from patients or carriers. Passage from mother to neonate during childbirth.
Incubation period – variable.
Period of communicability - presumably while lesions are present.
Susceptibility and resistance – Susceptibility is very low except in low host defense. It is
common in diabetes, HIVinfected; women are prone to vulvovaginitis in the third trimester of
pregnancy. Oral contraceptive users, individuals with prolonged steroid therapy are
susceptible.
Clinical manifestation
􀂃 Severe vulvar pruritis (prominent feature)
􀂃 vaginal discharge (scanty, whitish, yellow, thick to form curds, non-offensive)
􀂃 sore vulva due to itching
􀂃 speculum examination – thick whitish plugs attached to vaginal wall vaginal epithlium
bleeds when the plug is removed but th cervix is normal
Diagnosis
􀂃 Based on clinical grounds
􀂃 Microscopic demonstration of pseudohyphae or yeast cells in infected tissue or body fluids
(vaginal discharge)
􀂃 Culture (vaginal discharge)
Treatment
1. Nystatine vaginal pessary or
2. Miconazole or clotrmazele creams or
3. Keto conazole or
4. Fluconazele in recurrent cases
Prevention and control
1. Case treatment
2. Treatment of underlying medical conditions or predisposing factors

34
3. Gonorrhea
Definition
An acute or chronic purulent infection of the urogenital tract.
Infectious agent
Neisseria gonorrhea, the gonococcus
Epidemiology
Occurrence – worldwide, affecting both genders, especially sexually active adolescents and
young adults. Common in rural areas. Prevalent in communities of lower socio-economic
status. In most industrialized countries, the incidence has decreased during the past two
decades.
Reservoir - Strictly a human disease
Mode of transmission - almost always as a result of sexual activity
Incubation period - usually 2-7 days
Period of communicability - may extend for months in untreated individuals. Effective
therapy ends communicability within hours.
Susceptibility and resistance - Susceptibility is general. No immunity following infection
and reinfection is common.
Clinical manifestations
Males- Usually involves the urethra resulting in purulent discharge, dysurea and frequency.
Females - Females are usually asymptomatic. Vaginal discharge is common. Most common
site of infection is cervix, followed by urethra, anal canal and pharynx. Bartholinitis occurs
unilaterally. Salpingitis as a complication occurs in 20% of women. Neonates borne to
infected mothers develop a purulent discharge which exudes from between eyelids which are
edematous and erythematous 2 -3 days postpartum.
Diagnosis
􀂃 Gram stain of discharge (urethral, cervical, conjunctival discharge)
􀂃 Culture on selective media
Treatment
1. Co - trimoxazole or
2. Erythromycin or
3. Ceftriaxone can be used

35
Prevention and control
1. The same as syphilis
2. Application of 1% tetracycline in both eyes of newborne as soon as delivered.
4. HIV/AIDS
Definition
A severe, life - threatening clinical condition, first recognized as a distinct syndrome in 1981.
This syndrome represents the late clinical stage of infection with the human
immunodeficiency virus (HIV), which most often results in progressive damage to the
immune and other organ systems, including the CNS.
Infections agent
Human immuno-deficiency virus (HIV) (HIV-1 and HIV-2 )
Epidemiology
Occurrence - worldwide spread pandemic. HIV -1 infections are now distributed worldwide,
but are most prevalent in Sub Saharan Africa, the Americas, western Europe and souther and
Southeast Asia. HIV -2 has been found primarily in West Africa, with some cases in the
western hemisphere and other African countries that are linked epidemiological to West
Africa. The MOH 2002 report depicts the following about the HIV/AIDS situation in
Ethiopia:
- The HIV prevalence rate for the country as a whole is estimated at 6.66 percent. The
estimated HIV prevalence rate for urban areas is 13.7 percent
- Prevalence rates for some urban centers other than Addis Ababa are much higher than the
rate for Addis Ababa.
- The estimated rural prevalence rate is 3.7 percent, which is 25 percent of Addis Ababa’s
rate.
- HIV seems to be driving the TB epidemic in Ethiopia.
- The highest prevalence of HIV is seen in the age group 15 to 24 .The figure is worrying as
it represents “recent” infections.
Among the top ten leading causes of deaths, AIDS ranked 9t with 0.8% in 1993 E.C.
Reservoir - Humans
Mode of transmission – Mainly through sexual exposure and exposure to blood or tissues .
Moreover, transplacenta transmission from an infected mother to the fetus.
Incubation period- variable. Although the time from infection to the development of
detectable antibodies is generally 1-3 months, the time from HIV infection to diagnosis of

36
AIDS has an observed range of less than 1year to 10years or longer. About half of infected
adults will have developed AIDS within 10 years after infection.
Period of communicability - unknown. Presumed to begin early after onset of HIV infection
and extend throughout life.
Susceptibility and resistance - unknown, but susceptibility presumed to be general.
Susceptibility is increased in the presence of other STDs, especially those with ulcerations.
Clinical manifestations
Acute HIV syndrome. Occurs 3 - 6 weeks after primary infection. Clinical findings in the
acute syndrome are: fever, pharyngitis, lymphadenopathy, head ache, retro-orbital pain,
arthralgias, myalgias, lethargy or malaise, anorexia, weight loss, nausea or vomiting or
diarrhea. Meningitis, Encephalitis, peripheral neuropathy, myopathy, erythematous
maculopupular rash, mucocutaneous ulceration.
Late complications of HIV infection
These result from opportunistic infections like pneumocystis carinii pneumonia,
Tuberculosis, cryptococcal meningitis, etc.
Diagnosis
􀂃 Based on clinical ground in the late stage
􀂃 Based on serologic test in the early and late stage
Treatment
1. No specific treatment.
2. Treatment of opportunistic infections.
3. Use of anti-HIV drug to reduce transmission of the virus to the fetus of pregnant mothers
reduces fetal infection.
Prevention and control
1. prevention and control methods for other STDs

37
 ZOONOTIC DISEASES
Introduction
Infectious diseases transmitted under natural conditions between vertebrate animals and man are
called zoonosis. For most of these diseases, man is a dead-end of th transmission cycle. This
means under normal conditions, man will not infect other human beings.
1. Brucellosis
Definition
A systemic bacterial disease with acute or insidious onset transmitted to humans from infected
animals.
Infectious agent
Brucella melitensis (most common worldwide), acquired primarily from goats, sheep and
camels.
B. abortus from cattle
B. suis from pigs
B. canis from dogs
These are small aerobic gram-negative bacilli, intracellular parasites.
Epidemiology
Occurrence- Worldwide. Predominantly an occupational disease of those working with infected
animals or their tissues especially farm workers, veterinarians and abattoir workers, which is
more frequent among males. Outbreaks can occur among consumers of raw milk and milk
products, especially unpasteurized soft cheese from cows, sheep and goats.
Reservoir- cattle, swine, goats and sheep, pet dogs.
Mode of transmission- by contact with tissues, blood, urine, vaginal discharges, aborted fetuses
and especially placentas (through breaks in the skin). Most commonly through ingestion of raw
milk and dairy products from infected animals (raw meat or bone marrow). Airborne infection
occurs in humans in laboratories and abattoirs.
Incubation period- may last about 1-3 weeks but may be as long as several months.
Period of communicability- no evidence of communicability from person to person.
Susceptibility and resistance- Severity and duration of clinical illness are subject to wide
variation. Duration ofacquired immunity is uncertain.
Clinical manifestation
􀂃 Abrupt onset of symptoms

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􀂃 Most common symptoms are: Fever, chills, diaphoresis, headache, myalgia, fatigue, anorexia,
joint and low back pain, weight loss, constipation, sore throat, and dry cough.
􀂃 Physical examination reveals
- Often no abnormalities and patient look well Some are acutely ill, with pallor,
lymphadenopathy, hepatosplenomegally, arthritis, spinal tenderness, epididymoorchitis, skin
rash, meningitis, cardiac murmurs, or pneumonia
- Reactive asymmetric polyartaritis (knees, hips, shoulders, sacroiliac and sternoclavicular joints)
Diagnosis
􀂃 Exposure and consistent clinical features
􀂃 Serology- raised levels of B. agglutinin
􀂃 Blood or bone marrow culture
Treatments
􀂃 Doxycyline + aminogrycoside for 2 weeks followed by Doxycycline + Rifampcin for 4-8
weeks is the most effective regimen.
􀂃 In pregnancy and in children less than 7 years, Bacterium and Rifapcin for 8-12 weeks
N:B 4-14 days after the initiation of therapy, patients become afebrile and constitutional
symptoms disappear but enlarged liver and spleen return to normal size within 2-4 weeks.
Prevention and Control
1. Control depends on elimination of the disease among domestic animals Educate people not to
drink untreated milk or eat products made from untreated milk.
3. Educate farmers and slaughterhouse workers and those in meat processing plants and butcher
shops as to the nature of the disease and the risk in the handling of carcasses and products of
potentially infected animals.
4. Educate hunters to use barrier precaution (gloves and clothing).
5. Eliminate infected animals.
6. Pasteurize milk; cook meat and bone well.
7. Proper disposal of placenta, discharges or fetus from an aborted animal. Disinfect
contaminated areas.
2. Rabies
Definition
It is almost invariably fatal: acute vial encephalomyelitis (attacking brain and meninges).

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Infectious agent
Rabies virus
Epidemiology
Occurrence- Worldwide in wildlife particularly in developing countries. It is primarily a disease
of animals (zoonotic). It is primarily an infection of carnivores transmitted through bite.
Reservoir- Dog is common in urban areas; in the wild, wild carnivores and bats are reservoirs.
Mode of transmission- Transmitted with saliva of rabid animal introduced by a bite or scratch.
Transmission from man to man is dead-ended.
Incubation period- Usually 3-8 weeks
Period of communicability -Usually 3-7 days before the onset of the disease and throughout the
course of the disease.
Susceptibility and resistance- All mammals are susceptible to varying degrees. Humans are
more resistant to infection than several animal species.
Clinical Manifestation
The clinical manifestation, which is the same in all species including humans, has 3 phases:
􀂃 Prodromal phase
􀂃 Excitatory phase
􀂃 Paralytic phase
Prodromal phase: Onset is heralded by a sense of apprehension, headache, fever and nausea,
abnormal sensations at the site of inoculation (bite) is most significant, (i.e. paraesthesia, tingling
sensations at the bite site).
Excitatory phase or Aerophobia: Slightest sound/wind excites the victim, irritability, restless,
nervousness, tendency to bite, are some of the symptoms.
Paralytic phase: Spasm of swallowing muscles leads to drooling of saliva and fear of water
(hydrophobia). Delirium and convulsions form and death is often due to respiratory muscle
paralysis.
Diagnosis
􀂃 History of bite by known rabid animal and the bitten person show typical symptoms leading to
clinical diagnosis.
Treatment
1. Wound Care
􀂃 Wash the wound with soap and water thoroughly to decrease the viral load.

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􀂃 If there is bleeding cover the wound.
􀂃 Never suture the wound as this will spread the virus.
2. Start anti-rabies vaccine immediately if it is proved to be rabid animal bite.
Prevention and control
1) Immunize all dogs and cats.
2) Detain and clinically observe for 10 days any healthy appearing dog or cat known to have
bitten a person.
3) Post exposure prophylaxis
􀂃 Treatment of bite wounds
􀂃 Specific immunologic protection
4) Keep dogs and cats at home.
5) Destroy stray animals where rabies is endemic.
3. Anthrax
Definition
An acute bacterial disease usually affecting the skin, but which may very rarely involve the
oropharynx, lower respiratory tract, mediastinum or intestinal tract.
Infectious agent
Bacillus anthracis, spore forming bacteria.
Epidemiology:
Occurrence- Worldwide. Primarily a disease of herbivores. Humans and carnivores are
incidental hosts. Primarily an occupational hazard of workers who process hides, hair (especially
from goats), bone and bone products and wool: and of veterinarians and agriculture and wildlife
workers who handle infected animals. Human anthrax is common (endemic) in those agricultural
regions of the world where anthrax in animals is common, including countries in South and
Central America, southern and eastern Europe, Asia and Africa.
Reservoir- Animals, normally herbivores, both livestock and wildlife, shed the bacilli in
terminal hemorrhages or spilt blood at death. On exposure to air, the vegetative forms sporulate,
and the spores of B. anthracis, which are very resistant to adverse environmental conditions and
disinfections, may remain viable in contaminated soil for many years after the source animal
infection has terminated. Dried or processed skins and hides of infected animals may harbor the
spores for years and are the fomites by which the disease is spread worldwide.
Mode of transmission-

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􀂃 Cutaneous anthrax: Contact with tissues of animals (Cattle, sheep, goats, horses, pigs and
others) dying of the disease. Bite of flies that had partially fed on such animals, contaminated
hair, wool, hides, or products made from them such as drums or brushes or contact with soil
associated with infected animals.
􀂃 Inhalation anthrax: inhalation of spores in risky industrial processes such as tanning of hides,
or wool or bone processing, where aerosols of B. antracis spores may be produced.
􀂃 Intestinal and oropharyngeal anthrax: ingestion of contaminated meat; but there is no evidence
that milk from infected animals transmits anthrax.
N:B. The disease is transmitted among grazing animals through: contaminated soil and feed, and
among omnivorous bone meal or other feeds and among wildlife from feeding on anthrax
carcasses.
􀂃 Vultures have been reported to spread the organism from one area to another.
Incubation period- A few hours to seven days; most cases occur within 48 hours of exposure.
Period of communicability- transmission from person to person is very rare. Articles and soil
contaminated with spores may remain infective for decades.
Susceptibility and resistance- uncertain
Clinical manifestation
Cutaneous Anthrax
􀂃 Approximately 95% of human cases of anthrax are cutaneous form and about 5% are the
inhalation form.
􀂃 Found on exposed areas of skin (head, neck, face and hands).
􀂃 Small red macules appear.
􀂃 Lesion- progress to papule, vesicle or pustule during the next week and formation of an ulcer
with blackened necrotic eschar surrounded by a highly characteristic, expanding zone of brawny
edema. The early lesion may be pruritic but painless.
􀂃 Small satellite vesicle may surround the original lesion and painful non-specific regional
lymphadenitis is common.
􀂃 Most patients are afebrile with mild or no constitutional symptoms; in severe cases, however,
edema may be extensive and associated with shock.
􀂃 Spontaneous healing occurs in 80-90% of untreated cases but edema may persist for weeks.
􀂃 In 10-20% of cases, infection progresses, bacteriadevelops and is often associated with high
fever and rapid death.

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Inhalation anthrax
􀂃 Presentation of symptoms of severe viral respiratory diseases makes early diagnosis difficult.
􀂃 Acute phase supervenes after 1-3 days. With increasing fever, dyspnea, stridor, hypoxia, and
hypotension usually leading to death within 24 hours.
Gastrointestinal Anthrax- Symptoms are variable and include:
􀂃 Fever, nausea and vomiting, abdominal pain, blood, diarrhea, and sometimes rapidly
developing ascites.
􀂃 Diarrhea is occasional and massive in volume.
Oropharyngeal anthrax
􀂃 Fever, sore throat, dysphagia, painful regional
lymphadenopathy toxemia, respiratory distress may be
evident.
􀂃 The primary lesion is most often on the tonsils.
Diagnosis
􀂃 Clinical data
􀂃 Gram stain of wound discharge
􀂃 Culture from the wound discharge or blood
Treatment
For Cutaneous anthrax
1. Penicillin-G IV until edema subsides and with subsequent oral penicillin to complete the
course (adults). For Penicillin-sensitive adults, Ciprofloxacin, erythromycin, Tetracycline,
Chloramphenicol can be substituted.
2. Clean and cover the cutaneous lesions.
For Inhalation anthrax, Gastrointestinal and Anthrax
meningitis
􀂃 High dose of penicillin is recommended.
Prevention and control
1. Decontaminate wool and goat’s hair and improvement of working condition for handlers of
animal products. Vaccination of susceptible groups and domestic herbivores.
3. Carcasses of animals should be buried intact.

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4. Butchering of infected animals should be avoided.
5. Education in mode of transmission and in care of skin abrasions for employees handling
potentially contaminated articles.
6. Dust control and proper ventilation in hazardous industries.
7. Treat all animals exposed to anthrax with Tetracycline or penicillin.

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 FOOD-BORNE DISEASES (FOOD POISONING, FOOD-BORNE INTOXICATIONS,
FOOD-BORNE INFECTION)
Introduction
Food-borne diseases, including food-borne intoxications and food-borne infections, are terms
applied to illnesses acquired by consumption of contaminated food. They are frequently and
inaccurately referred to as food poisoning. While these terms would include illnesses caused by
chemical contaminants (heavy metals and organic compounds), this chapter will cover illnesses
caused by toxins elaborated by bacterial growth in the food before consumption (staphylococcus
aureus and botulism) and a food-borne infection (salmonellosis).
1. Staphylococcal Food Poisoning (intoxication)
Definition
An intoxication (not infection) of abrupt and sometimes violentonset.
Infectious agent (Toxic agent)
Several enterotoxins of staphylococcus aureus, stable at boiling temperature. Staphylococci
multiply in food and produce the toxins.
Epidemiology
Occurrence- Widespread and relatively frequent
Reservoir- Humans in most instances; occasionally cows with infected udders.
Mode of transmission- By ingestion of a food product containing staphylococcal enterotoxin.
Foods involved are particularly those that come in contact with food handlers’ hands, either
without subsequent cooking or with inadequate heating or refrigeration, (e.g. salad, sandwiches,
sliced meat and meat products, pastries, etc.). When these foods remain at room temperature for
several hours before being eaten, toxin-producing staphylococci multiply and elaborate the
heatstable toxin. The organisms may be of human origin, from purulent discharges of an infected
finger or eye, abscesses, nasopharynyeal secretions.
Incubation period- 30 minutes to 8 hours, usually 2-4 hours.
Period of communicability- not applicable
Susceptibility and resistance- Most people are susceptible.
Clinical Manifestation
􀂃 Sudden onset of vomiting and watery diarrhea
􀂃 Fever and abdominal cramp
􀂃 The intensity of illness may require hospitalization.

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Diagnosis
􀂃 Group of cases with characteristic acute predominantly upper gastrointestinal symptoms and
the short interval between eating a common food item and the onset of symptoms.
􀂃 Culture –staphylococcal recovery (≥105organisms per gram of food) or detection of
enterotoxin from an epidemiologically implicated food item confirms the diagnosis.
Treatment
1. Fluid and electrolyte replacement if fluid loss is significant particularly in severe cases.
Prevention and Control
1. Educate food handlers in strict food hygiene, sanitation and cleanliness of kitchens, proper
temperature control, handwashing, cleaning of finger nails, need to cover wounds on the skin,
etc.
2. Reduce food-handling time (initial preparation to service) to an absolute minimum, with no
more than 4 hours at ambient temperature. Keep perishable food hot (>60c0) or cold (below
10c0).
3. Temporarily exclude people with boils, abscesses and other purulent lesions of hands, face or
nose from food handling.
2. Botulism
Definition
A paralytic disease that begins with cranial nerve involvement and progresses caudally to involve
the extremities.
Infectious agent (Toxic agent)
Toxin produced by Clostridium botulinum (Neurotoxin)
Epidemiology
Occurrence- Worldwide occurrence. Home-canned foods, particularly vegetables, fruits and less
commonly with meat and fish. Outbreaks have occurred from contamination through cans
damaged after processing. Commercial products occasionally cause outbreaks but some of these
outbreaks have resulted from improper handling after purchase. Food-borne botulism can occur
when a food to be preserved is contaminated with spores.
Reservoir- The bacteria is found in the soil and in the intestine of animals.
Mode of transmission- Food ingestion in which preformed toxin is found.
Incubation period- Neurological symptoms of food-borne botulism usually appear within 12-36
hours, sometimes several days, after eating contaminated food.
Period of communicability- not communicable

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Susceptibility and resistance- Susceptibility is general.
Clinical Manifestations
􀂃 Illness varies from a mild condition to very severe disease that can result in death within 24
hours.
􀂃 Symmetric descending paralysis is characteristic and can lead to respiratory failure and death.
􀂃 Cranial nerve involvement marks the onset of symptoms; usually produces diplopia,
dysphagia. Weakness progresses, often rapidly, from the head to involve the neck, arms, thorax
and legs; the weakness is occasionally asymmetric.
􀂃 Nausea, vomiting, abdominal pain may proceed or follow the onset of paralysis.
􀂃 Dizziness, blurred vision, dry mouth, and occasionally sore throat are common.
􀂃 No fever
􀂃 Ptosis is frequent.
􀂃 Papillary reflexes may be depressed: fixed or dilated pupils are noted in half of patients. The
gag reflex may be suppressed; deep tendon reflexes may be normal or decreased.
􀂃 Paralytic illus, severe constipation and urinary retention are common.
Diagnosis
􀂃 Clinical- afebrile, mentally intact patients who have symmetric descending paralysis without
sensory findings.
􀂃 Appropriate History.
􀂃 Demonstration of organisms or its toxin in vomitus, gastric fluid or stool is strongly suggestive
of the diagnosis
􀂃 Wound culture
Treatment
1. Hospitalize the patient and monitor closely.
3. Intubation and mechanical ventilation may be needed.
4. Antitoxin administration after hypersensitivity test to horse serum.
5. Emesis and lavage if short time after ingestion of food to decrease the toxin.
Prevention and control
1. Ensure effective control of processing and preparation of commercially canned and preserved
foods.

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2. Education about home canning and other food preservation techniques regarding the proper
time, pressure and temperature required to destroy spores, the need for adequate refrigeration,
storage, boiling with stirring home-canned vegetables for at least 10 minutes to destroy botulinal
toxin.
3. Canned foods in bulging containers should not be used, eaten or tasted.
3. Salmonellosis
Definition
A bacterial disease commonly manifested by an acute enterocolitis.
Infectious agent
Salmonella typhimurium and Salmonella enteritidis are the two most commonly reported.
Epidemiology:
Occurrence- Worldwide
Reservoir- Domestic and wild animals including poultry, swine, cattle, rodents and pets
(tortoises, dogs, cats and humans) and patients or convalescents are carriers, especially of mild
and unrecognized cases.
Mode of transmission: - ingestion of organisms in food derived from infected food animals or
contaminated by feces of an infected animal or person. Raw and under-cooked eggs and egg
products, raw milk and its products, contaminated water, meat and its products, poultry and its
products. Consumption of raw fruits and vegetables contaminated during slicing.
Incubation period –from 6 –72 hours, usually about 12-36 hours
Period of communicability- extremely variable through the course of infection; usually several
days to several weeks.
Susceptibility and resistance- Susceptibility is general and increased by achlorhydria, antacid
therapy, gastrointestinal surgery, prior or current broad-spectrum antibiotic treatment, neoplastic
disease, immunosuppressive treatment and malnutrition.

Clinical manifestation
􀂃 Self-limited fever and diarrhea (bloody or dysenteric when colon is involved)
􀂃 Nausea, vomiting and abdominal cramp
􀂃 Microscopic leukocytosis.
Diagnosis
􀂃 Blood culture initially

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􀂃 Stool, culture
Treatment
1. Symptomatic
2. If there is an underlying immunosuppressive disease (conditions like AIDS, lymphoma,
immunosuppressive treatment), treat the underlying cause.
Prevention and control
1. Improved animal rearing and animal marketing
2. Quality testing of the known and commonly contaminated foods
3. Avoid consuming raw or partially cooked eggs
4. Wear gowns and gloves when handling stool and urine and handwashing after patient contact.

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