Nies: Community/Public Health Nursing: Promoting the Health of Populations, 4th Edition

Chapter 23: Communicable isease

Chapter "# !utline / Notes Communicable isease and Healthy People 2010 $# Three of the focus areas for Healthy People 2010Immunization and Infectious Diseases, Sexually Transmitted Infections, and HIV; specific to communicable diseases. Healthy People 2010 includes goals for immunization and infectious diseases. ele!ant areas co!ered include" #. Vaccine pre!entable diseases. $. STIs. %. HIV&'IDS. (. Hepatitis. ). Tuberculosis. %# 'pplication of community*based health inter!entions based on recommendations from Healthy People 2010 can assist in interrupting or pre!enting disease transmission. C# 'nalysis of the underlying en!ironmental, socioeconomic, political, educational, employment, and health factors is important in de!elopment of inter!entions for disease pre!ention. Principles of "nfection and "nfectious isease !ccurrence $# &ulticausation The principle of multicausation emphasizes that an infectious agent alone is not sufficient to cause disease+the agent must be transmitted in the en!ironment to a susceptible host. %# 'pectrum of "nfection The spectrum of infections in!ol!es the follo,ing concepts" #. 'n infectious agent may contaminate the s-in or mucous membranes of a host, but not in!ade the host. $. 'n infectious agent may in!ade and multiply but produce a subclinical infection that is asymptomatic. %. 'n infectious agent may in!ade and multiply resulting in o!ert symptomatic infection. C# 'tages of "nfection #. 'n infectious agent that has in!aded and infected a host ,ill replicate until it can be shed from the host. This period of replication before shedding is called the latent period. $. The communicable period follo,s latency and begins ,ith shedding of the agent. %. The incubation period refers to the time from in!asion to the time ,hen disease symptoms first appear.

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# 'pectrum of isease !ccurrence .ontrol of infectious diseases in a population re/uires identifying and monitoring the occurrence of disease. #. Incidence" 0e, cases of infectious disease. $. 1ndemic" The consistent and expected le!el of a disease in a geographic area. %. 2utbrea-" The unexpected occurrence of an infectious disease in a limited geographical area during a limited period of time. (. 3andemic" The steady occurrence of disease o!er a !ery large geographical area 4e.g., continent of 'frica5 or ,orld,ide. ). 1pidemic" The unexpected increase of an infectious disease in a geographical area o!er an extended period of time. """# Chain of (ransmission Transmission can be conceptualized as a chain ,ith 6 connected lin-s" infectious agent, reser!oir, portal of exit, mode of transmission, portal of entry, and host susceptibility. $# "nfectious $gents Infectious agents include prions, !iruses, bacteria, fungi, protozoa. 1ach acts differently depending on intrinsic properties and ho, they interact ,ith their human host. Intrinsic properties include size, shape, chemical composition, gro,th re/uirements, and !iability. %# )eser*oirs The en!ironment in ,hich a pathogen li!es and multiplies is the reser!oir. These reser!oirs include humans. C# Portals of E+it and Entry 3athogens enter and lea!e a host through portals. #. .ommon portals of entry include the respiratory passages, mucous membranes, percutaneous in7ection, oral ca!ity, and through the placenta. $. .ommon portals of exit include respiratory secretions, !aginal secretions, semen, sali!a, lesion exudates, blood, and feces. # &odes of (ransmission 8odes of transmission may be direct or indirect. #. Direct transmission implies the immediate transfer of an infectious agent from an infected host or reser!oir to an appropriate portal of entry in the human host through physical contact such as touching, biting, -issing, or sexual contact, or through droplet spray. $. Indirect transmission is the spread of infection through a !ehicle of transmission outside the host. These may be contaminated fomites or !ectors. E# Host 'usceptibility 0ot all humans are e/ually susceptible for contracting an infection. Things that affect susceptibility include" #. 9iological and personal characteristics 4e.g., age5. $. :eneral health status. %. 3ersonal beha!iors. (. Immune system and immunization status.

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%rea-ing the Chain of (ransmission The chain of transmission can be disrupted by affecting any of the lin-s. $# Controlling the $gent #. Inacti!ating an agent is the principle behind disinfection, sterilization, and radiation of fomites. $. 'ntiinfecti!e drugs, such as antibiotics, anti!irals, antiretro!irals and antimalarials all play an important part in controlling infectious diseases. %# Eradicating the Nonhuman )eser*oir Treating these or eliminating common non*human reser!oirs for pathogens in the en!ironment 4e.g., ,ater, food, mil-, animals, insects, and se,age5 are effecti!e methods of pre!enting replication of pathogens and, thus, pre!enting transmission. C# Controlling the Human )eser*oir #. Treating infected persons can pre!ent transmission of pathogens that can be transmitted directly to others. $. ;uarantine and isolation is another method of controlling the reser!oir. # Controlling the Portals of E+it and Entry #. The transmission chain may be bro-en at the portal of exit by properly disposing of secretions, excretions, and exudates from infected persons. $. The portal of entry of pathogens also can be controlled by using barrier precautions 4mas-s, glo!es, condoms5, a!oiding unnecessary in!asi!e procedures, such as ind,elling catheters, and protecting oneself from !ectors. %. <ni!ersal 3recautions are another ,ay to control transmission !ia portals of exit or entry. E# "mpro*ing Host )esistance and "mmunity #. esistance is ability to ,ard off infections. 8any factors, such as age, general health status, nutrition, and health beha!iors contribute to a host=s resistance. $. Immunity, ho,e!er, is an incredible defense against infection. There are se!eral different -inds of immunity, each pro!iding resistance in different ,ays to different pathogens. a. 0atural immunity is an innate resistance to a specific antigen or toxin. b. 'c/uired immunity is deri!ed from actual exposure to the specific infectious agent, toxin, or appropriate !accine. There are $ types of ac/uired immunity" acti!e and passi!e. i. 'cti!e immunity is ,hen the body produces its o,n antibodies against an antigen, either as a result of infection ,ith the pathogen or introduction of the pathogen in a !accine. ii. 3assi!e immunity is the temporary resistance that has been donated to the host through transfusions of plasma proteins, immunoglobulins, and antitoxins, or from mother to neonate transplacentally. 3assi!e immunity lasts only as long as these substances remain in the bloodstream.

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Public Health Control of "nfectious iseases Infectious diseases are categorized as public or community health problems. 9ecause of their potential to spread and cause community*,ide or ,orld,ide emergencies, infectious diseases re/uire organized, public efforts for their pre!ention and control.

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$# (erminology: Control, Elimination and Eradication #. .ontrol of a communicable disease refers to the reduction of incidence or pre!alence of a gi!en disease to a locally acceptable le!el as a result of deliberate efforts. $. 1limination of a communicable disease in!ol!es controlling it ,ithin a specified geographical area such as a single country, an island, or a continent and reducing the pre!alence and incidence to near zero. 1limination is the result of deliberate efforts, but continued inter!ention measures are re/uired. %. 1radication in!ol!es reducing the ,orld,ide incidence of a disease to zero as a function of deliberate efforts, ,ithout a need for further control measures. %# efining and )eporting Communicable iseases #. Diseases are defined and classified according to confirmed cases, probable cases, laboratory*confirmed cases, clinically compatible cases, epidemiologically lin-ed cases, genetic typing, and clinical case definition. $. The .enters for Disease .ontrol and 3re!ention 4.D.5 has designated notifiable infectious diseases, that is, diseases that health care pro!iders must report to the local or regional health department. %. 9ecause state health departments ha!e the responsibility for monitoring and controlling communicable diseases ,ithin their respecti!e states, they determine ,hich diseases ,ill be reported ,ithin their 7urisdiction. Pre*ention: ,accines $# ,accines: .ord of Caution #. Information and recommendations on immunizations and !accine usage change regularly; therefore, health care pro!iders should see- the most current information on the .D. ,ebsite. $. 3recautions must be ta-en ,hen gi!ing any immunization. The most recent recommendations regarding ,hich immunizations to gi!e; to ,hom they should be gi!en; ho, they should be gi!en; and ho, they are to be transported, stored, and administered can be obtained from the .D.. %. The .D. produces Vaccine Information Statements 4VISs5 that explain to !accine recipients, their parents, or their legal representati!es both the benefits and ris-s of a !accine. >ederal la, re/uires that VISs be handed out before each !accination dose. %# (ypes of "mmuni/ations #. Immunizing agents can include !accines as ,ell as immune globulins or antitoxins. Vaccination is a narro,er term referring to the administration of a !accine or toxoid to confer acti!e immunity by stimulating the body to produce its o,n antibodies. $. Vaccines can be li!e but ,ea-ened 4attenuated5 or they may be -illed 4inacti!ated5 lea!ing only the antigenic property necessary to stimulate the human immune system to produce antibodies. %. Immune globulins and antitoxins are solutions that contain antibodies from human or animal blood and are introduced into a patient to pro!ide passi!e protection ,ithout initiating the immune system to produce an immunogenic response.

C# ,accine 'torage, (ransport, and Handling 1xposing the !accine to higher or lo,er temperatures than recommended may result in loss of potency and !accine failure. 8easures to insure safe storage include monitoring ,ith specialized thermometers, or indicators that change color if the temperature exceeds or falls belo, the recommended le!el. # ,accine $dministration The efficacy of the !accine can be ad!ersely affected if the !accine is not administered appropriately. outes !ary ,ith different !accines. E# ,accine 'pacing #. 'll children should be age*appropriately immunized and -ept up to date according to current recommendations of the '.I3. $. 'n interruption in the schedule does not re/uire that the entire series begin again. Ho,e!er, if !accines are administered at less than the recommended inter!als, they should not be counted as part of the primary series of immunization. %. .ompletion of the primary !accine series and recei!ing periodic booster doses as recommended are necessary to ensure protecti!e le!els of immunity. (. 'll !accines can be administered simultaneously ,ithout contraindication, except for yello, fe!er and cholera !accines, ,hich must be separated by at least three ,ee-s. ). ?i!e in7ectable !accines 4e.g., 88 and !aricella5 must be separated by at least four ,ee-s ,hen not gi!en simultaneously. 0# ,accine Hypersensiti*ity and Contraindications #. 'd!erse reactions are not common. These reactions can be from !accine components such as eggs, egg proteins, antibiotics, preser!ati!es, and ad7u!ants. 3atient allergies should be considered before administration of specific !accines. $. 8ild illness ,ith or ,ithout lo,*grade fe!er is not a contraindication for !accination. %. 3regnancy is not a contraindication for immunization using inacti!ated !accines, antitoxins, or immune globulins; ho,e!er, pregnant ,omen should a!oid li!e !accines including 88 , !aricella, and yello, fe!er unless the ris- of infection is !ery li-ely. (. Immunocompromised patients should not recei!e li!e !accines; ho,e!er, 88 can be administered to asymptomatic HIV*infected people and !aricella can be gi!en to people ,ith humoral immunodeficiency and some HIV* asymptomatic people as determined by their physician. @illed or inacti!ated !accines can be gi!en, but they may not produce an optimal antibody response. H# ,accine ocumentation The health care pro!ider is responsible for maintaining accurate records, including patient name, dates immunized, !accine type, !accine manufacturer, !accine lot number, date of the Vaccine Information Statement 4VIS5, and the name, title, and address of the person administering the !accine.

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"# ,accine 'afety and )eporting $d*erse E*ents and ,accine1)elated "n2uries To monitor actual and potential !accine*related problems, health care pro!iders must report specific post*!accination Aad!erse e!entsB to the Vaccine 'd!erse 1!ent eporting System 4V'1 S5. ,accine Needs for 'pecial 0roups ecommendation on immunizations and schedules for !accination are routinely updated and published by .D. on its ,ebsite. $# Healthy "nfants, Children, and $dolescents .urrent recommendations at the time of this ,riting is that students complete a schedule of ## childhood !accines by age #C months. The schedule is complex and includes the follo,ing" #. ( doses of diphtheria, tetanus, and acellular pertussis !accine 4DTa35. $. % doses of inacti!ated polio!irus !accine 4I3V5. %. # dose of measles*mumps*rubella !accine 488 5. (. % to ( doses of Hib con7ugate !accine. ). % doses of hepatitis 9 !accine 4Hep 95. 6. # dose of !aricella !accine. D. ( doses of a con7ugated pneumococcal !accine. C. Hepatitis ' !accine is also recommended for children aged $ to #C years li!ing in regions ,here hepatitis ' rates are t,ice the national a!erage. ecommendations also include a routine health care !isit at ## to #$ years of age to ensure that pre!iously un!accinated adolescents ,ould recei!e" #. Hep 9, !aricella !accine 4if no history of disease5. $. ' second dose of 88 !accine. %. ' booster dose of tetanus and diphtheria !accine 4Td5, if it has been more than ) years since their prior dose. 's the result of a slight increased ris- for meningococcal disease among freshman dormitory residents, the .D. recommends that !accination against meningococcal disease be pro!ided to freshman and other undergraduate students ,ho re/uest this !accine, although routine !accination is not recommended. %# $dults and the Elderly Vaccine*pre!entable diseases continue to cause thousands of hospitalizations and deaths in the 'merican adult and elderly populations. Te .D. recommends a routinely scheduled, pre!enti!e health care !isit for the )E*year*old adult to assess immunization status, administer Td and flu !accines and to assess ris- factors and need for pneumococcal !accine. #. The pneumococcal and influenza !accines can be administered simultaneously at the same !isit for those indi!iduals needing both !accines. $. The emergence of serious ne, drug*resistant pneumococci ma-es immunization particularly important for this population. C# "mmune 'uppressed #. ?i!e !irus or bacterial !accines are not recommended for persons ,ho are immune suppressed for any reason 4e.g., leu-emia, lymphoma, HIV&'IDS, congenital immunodeficiency, radiation, therapy ,ith an al-ylating agent, large doses of corticosteroids5.

$. The -illed or inacti!ated !accines can be gi!en according to the same recommended administration schedule as for the healthy person. # Pregnancy #. 88 and !aricella !accines are both contraindicated ,hen pregnancy is -no,n. $. 2ther li!e !irus !accines 4e.g., 23V and yello, fe!er5 are not recommended during pregnancy, but they can be administered and are recommended for susceptible pregnant ,omen ,ho li!e in areas or may tra!el to areas ,here there is a high ris- of exposure to these diseases. %. Inacti!ated !accines, toxoids, and immune globulin preparations are not contraindicated during pregnancy. (. Hepatitis 9, pneumococcal, meningococcal, and rabies !accines are recommended for at*ris- pregnant ,omen. E# ,accines for "nternational (ra*el #. The only !accine re/uired for tra!el to certain countries is yello, fe!er !accine. These countries re/uire a stamped and signed International .ertificate of Vaccination, ,hich can be obtained from any pro!ider authorized to administer yello, fe!er !accine. $. 2ther !accines 4e.g., typhoid5 may be recommended depending on the area, the season, and the li-elihood of exposure. Tra!elers can obtain the most current recommendations from the 2ffice of 2!erseas Tra!el at the .D.. ,"""# Healthy People 2010 3ocus on "mmuni/ation and "nfectious iseases Healthy People 2010 ob7ecti!es detailed three focus areas for infectious diseases. These highlight !accine pre!entable and other priority infectious diseases, excluding STIs and HIV. "4# Healthy People 2010 3ocus on 'e+ually (ransmitted "nfections 5'("s6 $# The rates of STIs in the <nited States are among the highest in the industrialized ,orld and account for CDF of the top #E infections reported to the .D.. %# 3opulations disproportionately affected include adolescents, young adults, ,omen, minorities, and the poor. #. Teenage girls in particular may be more susceptible to STIs because they ha!e fe,er protecti!e antibodies to STIs and a cer!ix that is biologically immature. $. Gomen are at higher ris- for contracting STDs than men because they ha!e anatomical differences that enhance transmission of disease and ma-e diagnosis difficult. C# .omplications from undiagnosed STIs occur more fre/uently and are more se!ere in ,omen. #. 3el!ic inflammatory disease 43ID5 resulting from undetected STIs can lead to infertility, ectopic pregnancy, o chronic pel!ic pain. $. 'n infected ,oman ,ho transmits an STI to her fetus during pregnancy or childbirth may experience spontaneous abortion, premature deli!ery, stillbirth, lo, birth ,eight, neonatal death, and, in the infant, chronic respiratory problems, blindness, and mental disabilities. %. .ertain strains of sexually transmitted human papilloma !irus 4H3V5 are associated ,ith cer!ical cancer.

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Healthy People 2010 3ocus on H",/$" ' $# HIV, a retro!irus, is the organism that causes the syndrome -no,n as 'IDS. >ollo,ing initial infection, the disease is typically asymptomatic for months to years. %# HIV usually manifests gradually ,ith conditions that result from inade/uate immune system function as the !irus slo,ly attac-s the body=s immune system. 2!er time, the body loses its ability to fight illnesses and opportunistic infections occur and become recurrent. C# HIV infection is usually determined by the HIV antibody test, and the most commonly used form is the enzyme*lin-ed immunosorbent assay 41?IS'5. There may be false*positi!e findings, so the Gestern blot is fre/uently used to !erify the results. # Treatment for HIV and 'IDS is complex and changes fre/uently. The >D' has appro!ed many drugs for HIV infection and 'IDS*related conditions. 't present there are four classes of antiretro!iral drugs, each corresponding to different mechanisms ,hereby HIV ta-es in!ades the cells of the immune system. E# .D. continues to update recommendations for post exposure prophylaxis 43135 for occupational exposures. 'lthough the principles of immediate treatment follo,ing exposure ha!e not changed, the drugs and drug combinations ha!e changed. Pre*ention of Communicable iseases $# Primary Pre*ention 3rimary pre!ention of communicable diseases in!ol!es measures to pre!ent transmission of an infectious agent and to pre!ent pathology in the person exposed to an infection. Immunization is a primary pre!ention strategy. %# 'econdary Pre*ention Secondary pre!ention includes acti!ities for early detection and treatment of persons ,ho are infected. eporting infectious diseases, in!estigating contacts, notifying partners, finding ne, cases, and isolating cases are examples of secondary pre!ention. C# (ertiary Pre*ention Tertiary pre!ention includes acti!ities in!ol!ed in caring for persons ,ith an infectious disease to ensure that they are cured or that their /uality of life is maintained. 8aybe the most important part of the treatment process is to ensure that the person ta-es their antimicrobials completely and effecti!ely.