Beruflich Dokumente
Kultur Dokumente
Communicable disease
I. Common communicable diseases in Malaysia II. National policies & procedures III. Prevention & control of 3 common communicable diseases in Malaysia Non-communicable disease I. Common non-communicable diseases in Malaysia II. Prevention & control of 3 common noncommunicable diseases in Malaysia
COMMUNICABLE DISEASE
Introduction
Dengue is a viral infection transmitted by mosquitoes, mainly the Aedes aegypti species The virus is contracted from the bite of a striped Aedes aegypti mosquito that has previously bitten an infected person. One mosquito bite can inflict the disease There are four strains or serotypes of dengue virus namely DEN-1, DEN-2, DEN-3 and DEN-4 The mosquito flourishes during rainy seasons but can breed in water-filled containers, year-round
Introduction
The virus is not contagious and cannot be spread directly from person to person. There must be a person-to-mosquito-to-another-person pathway Dengue haemorrhagic fever severe form of dengue. A second attack by dengue virus of a different serotype from the first infection Approximately 1% of patients with dengue infection progress to dengue haemorrhagic fever
World-Wide Distribution
Malaysia Penang 1962 The first major dengue outbreak in Malaysia Penang 1973 A nationwide outbreak Kuala Lumpur Since then dengue has become a major public health problem in the country Dengue cases/deaths mounts parallel with the rapid development, expansion of urban areas & population density (as of Sept 2008 = 27,730,000 inhabitants)
1998
1999 2000 2001 2002 2003
27381
10146 7103 16386 15493 31545
82
37 45 50 54 72
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
2004
2005 2006 2007 2008
33895
39654 34386 48846 49355
102
107 70 98 112
120 100 80 60 40 20 0 1998 1999 2000 2001 2002 37 45 50 82
Year
102 72 54
107
P/S : 28.12.2008 03.01.2009, 1157 cases were reported with 4 deaths so far
2003
2004
2005
2006
2007
2008
Year
Diagnosis
Classic symptoms : high fever, a petechial rash with thrombocytopenia & relative leukopenia (decrease in the number of circulating WBC in the blood) WHO definition of DHF: I. Fever II. Haemorrhagic tendency [positive tourniquet test (> than 20 petechiae per square inch), spontaneous bruising, bleeding from mucosa, gingiva, injection sites, vomiting blood or bloody diarrhea] III. Thrombocytopaenia [<100,000 platelets per mm]. IV. Evidence of plasma leakage [rise in hematocrit level > than 20%] Serology (identification of antibodies in the blood serum) & polymerase chain reaction (PCR) to confirm the diagnosis of dengue if clinically indicated
Symptoms
Sudden high fever (39-41.5C) for 2 to 7 days Headache Pain behind the eyes Muscle pain, joint pain, bone pain (break-bone fever) After 1 to 2 days of fever, the patient develops initial rash with discoloured spots, often described as Isles of white in a sea of red Second rash may develop to palms and soles, and skin may peel off (desquamate) & body temperature drops
Treatments
No specific antiviral treatment, only supportive treatment is given to such patients If the patient is dehydrating, adequate fluids are to be taken Intravenous fluid is administered if the patient is unable to maintain oral intake For severe body ache, painkillers may be needed For severe headache and for joint and muscle pain, acetaminophen/paracetamol and codeine may be given If there is significant bleeding, blood or platelet transfusion will be carried out Note : Aspirin should be avoided as this drug may worsen the bleeding tendency (because of its anticoagulant effects & the increased risk of developing Reye syndrome).
Introduction
Mycobacterium tuberculosis, a small, Aerobic, non-motile bacillus When people with active pulmonary TB cough, sneeze, speak, sing, or spit, they expel infectious aerosol droplets 0.5 to 5.0 m in diameter A single sneeze can release up to 40,000 droplets Each 1 of these droplets may transmit the disease, since the infectious dose of tuberculosis is very small (the inhalation of fewer than 10 bacteria may cause an infection)
Diagnosis
Investigations
Treatment
Treatment
Description of regimen Intensive Phase: Daily doses x 2 months (Total of 56 doses) SHRZ SHR EHRZ RHZ Continuation Phase: Biweekly doses x4 months (Total of 32 doses) SHR RH RH (daily)
8 weeks daily SHRZ 16 weeks biweekly 8 weeks daily EHRZ 16 weeks biweekly RH 8 weeks daily RHZ 16 weeks daily RH (preferred regimen for paediatric cases) 8 weeks daily SHRZ 16 weeks biweekly RH 8 weeks daily RH 16 weeks biweekly RH
SHRZ RHZ
RH RH
Introduction
Human Immunodeficiency Virus A unique type of virus (a retrovirus) Invades the helper T cells (CD4 cells) in the body of
Introduction
Acquired Immunodeficiency Syndrome HIV is the virus that causes AIDS Disease limits the bodys ability to fight infection due to markedly reduced helper T cells mechanism)
Definition Of AIDS
Transmission
I. Blood products II. Semen III. Vaginal fluids Intravenous drug abuse I. Sharing Needles (Without sterilization increases the chances of contracting HIV) II. Unsterilized blades
Transmission
Through sex
I. Oral II. Anal Mother to babies I. Before birth II. During birth
Stage 1 - Primary
Short, flu-like illness - occurs one to six Mild symptoms Infected person can
infect other people weeks after infection
Stage 2 - Asymptomatic
Lasts for an average of ten years This stage is free from symptoms There may be swollen glands The level of HIV in the blood drops to low levels HIV antibodies are detectable in the blood
Stage 3 - Symptomatic
The immune system deteriorates Opportunistic infections and cancers start to appear
Investigations
Investigations
Investigations
Orasure
I. The only FDA approved HIV antibody II. As accurate as blood testing III. Draws blood-derived fluids from the gum tissue IV. NOT A SALIVA TEST!
Treatment
Treatment
Membership Of HIACC
The Infection Control Doctor (Chairman) Medical Microbiologist (if not available, scientific officer in microbiology) The Infectious Disease Physician / Paediatrician The Infection Control Sister or the most senior infection control nurse (ICN) The Director /Deputy Director of the hospital A consultant virologist A consultant physician or surgeon A consultant pediatrician A consultant anaesthesiologist /intensivist A representative each from all major clinical departments (preferably at specialist or consultant level) The Nursing Director A pharmacist Senior representative from the hospital support service concessionaire
1. Administrative control (managerial) The most important measures of TB infection control is to prevent exposure and reduce transmission to health care workers and patient: I. Written TB Infection Control Plan II. Workplace Risk Assessment III. Triage and screening of patients IV. Early diagnosis, prompt treatment and isolation V. Training and education of health care workers VI. Patient education
2. Environmental control Prevent the spread & reduce the concentration of infectious droplet in the air Type of environmental control includes: I. Maximizing natural ventilation through open and free flow ambient air with open windows II. More complex methods: o Ventilation system e.g. local exhaust ventilation (LEV) o Negative pressure rooms or airborne infection isolation (AII) room o High Efficiency Particulate Air (HEPA) filtration to remove infectious particles o Ultraviolet germicidal irradiation (UVGI) to sterilize the air
3. Personnel protective equipment (PPE) The use of appropriate PPE is important and HCW must be trained to use PPE correctly 4. Screening for HCW I. Health care workers should be screened for Tuberculosis whenever they are symptomatic II. Chest radiograph and Tuberculin Skin Test are not routinely recommended 5. Infection control in specific area I. Inpatient settings II. Sputum induction area or room III. Outpatient settings and emergency department IV. Pharmacy
I. Inpatient setting Placed in AII room (Airborne Infection Isolation /Negative Pressure) TB patients should be cohorted from non tuberculosis patient, infectious from non infectious TB patients Isolation ward or area with maximum natural ventilation, mechanical ventilation by local exhaust ventilation and air cleaning methods
I. Inpatient setting All patients suspected or confirm TB should be educated about the importance of cough etiquette and wear surgical mask or close the mouth/nose when sneezing or coughing All HCW should use PPE (N95 mask) when handling infectious, non infectious or unconfirmed cases TB Only minimum number of visitors should be allowed to visit active TB patient in the ward. Protections for visitor are similar to medical staff
II. Sputum induction area/room An area or room with local exhaust ventilation (e.g., booths with special ventilation) or alternatively in a room that meets the requirements of an AII room N95 disposable respirator should be worn by HCWs performing sputum inductions on a patient with suspected or confirmed infectious TB disease After sputum induction is performed, allow adequate time before performing another procedure in the same room
III. Outpatient & Emergency Department Triage: o Triaging patient at the counter should be done to identify high risk patients by history taking (patient with history of cough for more than 2 weeks) o Specific waiting area or room for patients are recommended Signage directing patients with chronic cough to go to specific or identified counter. These patients should be provided with surgical mask. Provide N95 respirator for HCW in-charge of triaging
III. Outpatient & Emergency Department Educate patient with suspected or confirmed infectious TB disease on strict respiratory hygiene and cough etiquette Sputum induction room should be made available at OPD Ideally patients should be seen in a designated consultation room for TB equipped with appropriate environmental control
IV. Pharmacy Cut down patient mix/movement at pharmacy. Patient to collect medication at chest clinic or special counter at pharmacy or other options Dispensing should be done at special counter and positive pressure from pharmacy area out Allocate special code number or counter for TB infectious patients to collect medications Pharmacist or assistant pharmacist on duty at that counter must wear N95 mask when dealing with TB infectious patients Provide priority service to TB patients
V. Bronchoscopy suite Postpone non-urgent procedures on TB patients until the patient is determined to be noninfectious In urgent cases (e.g. massive haemoptysis), bronchoscopist and the assistants should wear N95 respirator and face shield for protection Air cleaning system should be installed in the bronchoscopy suite Ventilation system must be operated and maintained efficiently Tuberculosis culture laboratory must have a wellmaintained and properly functioning biological safety
VI. Laboratories All specimens suspected of containing M. tuberculosis (including specimens processed for other microorganisms) should be handled in a Class I or II biological safety cabinet (BSC) Standard personal protective equipment should be available and consists of:
o Laboratory coats - which should be left in the laboratory before going to non-laboratory areas o Disposable gloves - Gloves should be disposed of when work is completed, the gloves are overtly contaminated, or the integrity of the glove is compromised o Face protection (e.g., goggles, full-face piece respirator, face shield, or other splatter guard) should also be used when manipulating specimens inside or outside a BSC o Respiratory protection (N95) should be worn
lower than commonly used in practice can rapidly inactivate HIV Reusable instruments or devices should be sterilized or receive high-level disinfection before reuse Cleaning and removal of soil should be done routinely Germicide effective against HIV is a solution of sodium hypochlorite (1 part household bleach to 99 parts water or 1/4 cup bleach to 1 gallon of water) prepared daily Bleach, however, is corrosive to metals (especially aluminum) and should not be used to decontaminate medical instruments with metallic parts
used to decontaminate spills of blood or other body fluids In patient-care areas, visibly soiled areas should first be cleaned and then chemically decontaminated (moistened with germicide and air dry) In the laboratory, large spills of cultured or concentrated infectious agents should be flooded with a liquid germicide before cleaning, then decontaminated with fresh germicidal chemical after organic material has been removed
decontaminating procedures CDC recommends barrier precautions (face shields, masks, gowns, etc.) to prevent contact with droplets and splashes
1. Patients isolation I. Dengue patient need not be nursed in isolation room but an air-conditioned or an naturalventilated room is preferred II. If a natural-ventilated room is used, it is suggested to put mosquito nets to all the windows in the room III. If both facilities are not available, then the patients can be nursed in the general ward IV. Specific measures to avoid mosquito bites should be considered
2. Prevention of vector transmission I. Source elimination/reduction for Dengue fever II. Source elimination or reduction is the method of choice for mosquito control when the mosquito species targeted are concentrated in a small number of discrete habitats
2. Prevention of vector transmission III. Among the suggested measures to make sure that there will be no breeding grounds for mosquito in the area are: The larval habitats may be destroyed by filling depressions that collect water, by draining swamps, or by ditching marshy areas to remove standing water Container-breeding mosquitoes need to be identified and removed
2. Prevention of vector transmission III. Among the suggested measures to make sure that there will be no breeding grounds for mosquito in the area are: Water in cans, cups, and rain barrels around hospitals should be covered Chemical insecticides can be applied directly to the larval habitats Other methods, which are less disruptive to the environment, are usually preferred: o Oil may be applied to the water surface, suffocating the larvae and pupae o oil in use today are rapidly biodegraded
3. Biological agents Toxins from the bacterium Bacillus thuringiensis var. israelensis (Bti) I. These products can be applied in the same way as chemical insecticides II. Very specific, affecting only mosquitoes, black flies, and midges III. Insect growth regulators such as methroprene. Methoprene is specific to mosquitoes IV. Mosquito fish (Gambusia affinis) are effective in controlling mosquitoes in larger bodies of water
4. Avoidance from mosquito bite I. Insect repellents containing N,N-diethyl-3methylbenzamide (DEET) Adult-dose 95% DEET lasts as long as 10-12 hours, and 35% DEET lasts 4-6 hours Children, use concentrations of less than 35% DEET. Use sparingly and only on exposed skin. Remove DEET when no longer exposed II. Protective clothing (most effective is permethrinimpregnated) Limiting exposure during times of typical blood meals Wearing long-sleeved clothing
III. Insecticide-treated bed nets limited since Aedes mosquitoes bite during the day IV. Insecticides knockdown resistance may occur in some locations. Aedes mosquitoes bite during the day; hence, these measures must be taken during the day, particularly in the morning and late afternoon V. Fogging or area spraying is primarily reserved for emergency situations: Halting epidemics or rapidly reducing adult mosquito populations Fogging and area sprays must be properly timed to coincide with the time of peak adult activity
NON-COMMUNICABLE DISEASE
Introduction
Myocardial infarction Stroke (cerebrovascular accident) Heart failure Arrhythmia Valvular heart disease
Clinical Manifestations
Chest discomfort Peripheral edema & pulmonary congestion Dyspnea Palpitations Hypotension Syncope Heart murmur Elevated arterial pressure Abnormal ECG
Diagnosis
1. The underlying etiology Is the disease congenital, hypertensive, ischemic, or inflammatory in origin? 2. The anatomical abnormalities Which chambers are involved? Are they hypertrophied, dilated, or both? Which valves are affected? Are they regurgitant and/or stenotic? Is there pericardial involvement? Has there been a myocardial infarction? 3. The physiological disturbances Is an arrhythmia present? Is there evidence of congestive heart failure or myocardial ischemia?
Diagnosis
4. Functional disability. How strenuous is the physical activity required to elicit symptoms? The classification provided by the NYHA has been found to be useful in describing functional disability
Investigations
1. ECG 2. Non-invasive imaging (echocardiogram, radionuclide imaging, computed tomographic imaging, magnetic resonance imaging) 3. Blood tests (lipid determinants, C-reactive protein, cardiac function [BNP]) 4. Specialized invasive examination (cardiac catheterization, coronary arteriography) 5. Genetic test (monogenic cardiac disease)
Investigations
1. ECG 2. Non-invasive imaging (echocardiogram, radionuclide imaging, computed tomographic imaging, magnetic resonance imaging) 3. Blood tests (lipid determinants, C-reactive protein, cardiac function [BNP]) 4. Specialized invasive examination (cardiac catheterization, coronary arteriography) 5. Genetic test (monogenic cardiac disease)
Prevention
Control of risk factors Achieving optimal weight Physical activity Smoking cessation Diet control and balance Management of hypertension Management of hyperlipidemia Management of diabetes mellitus
Management
1. Continual assessment & re-assessment of health 2. Patient education of lifestyle changes and compliance to follow-up and therapies 3. Medical therapy antiplatelet therapy, lipid-lowering therapy (statin), antihypertensive therapy, hypoglycemic therapy * Not recommended hormone replacement, vitamin B, C, E, folate (for reduction of cardiovascular risk) 4. Surgical therapy coronary revascularization (CABG, PTCA), carotid endarterectomy
Introduction
that can affect any part of the body Other terms used are malignant tumours and neoplasms One defining feature of cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and which can then invade adjoining parts of the body and spread to other organs This process is referred to as metastasis. Metastases are the major cause of death from cancer
Pathophysiology
Pathophysiology
development of cancer The incidence of cancer rises dramatically with age, most likely due to a build up of risks for specific cancers that increase with age The overall risk accumulation is combined with the tendency for cellular repair mechanisms to be less effective as a person grows older
Risk Factors
Prevention
Increase avoidance of the risk factors Vaccinate against human papilloma virus (HPV) and
hepatitis B virus (HBV) Control occupational hazards Reduce exposure to sunlight Early detection Early diagnosis Screening
Tobacco use Being overweight or obese Unhealthy diet with low fruit and vegetable intake Lack of physical activity Alcohol use Sexually transmitted HPV-infection Urban air pollution Indoor smoke from household use of solid fuels
Management
Treatment goal is to cure disease, or prolong life while improving quality of life Surgery Radiotherapy Chemotherapy
Palliative care relieve rather than cure, symptoms caused by cancer Live more comfortably Relief from physical, psychosocial & spiritual problems
Introduction
Asthma
Asthma Causes
The strongest risk factors for developing asthma are a combination of genetic predisposition with environmental exposure to inhaled substances and particles that may provoke allergic reactions or irritate the airways, such as: 1. Indoor allergens (for example, house dust mites in bedding, carpets and stuffed furniture, pollution and pet dander) 2. Outdoor allergens (such as pollens and moulds) 3. Tobacco smoke 4. Chemical irritants in the workplace 5. Air pollution
Asthma Causes
arousal such as anger or fear, and physical exercise Even certain medications can trigger asthma: aspirin and other non-steroid anti-inflammatory drugs, and beta-blockers (which are used to treat high blood pressure, heart conditions and migraine) Urbanization has been associated with an increase in asthma. But the exact nature of this relationship is unclear
COPD Symptoms
Breathlessness (or a "need for air") Abnormal sputum (a mix of saliva and mucus in the
airway) Chronic cough Daily activities, such as walking up a short flight of stairs or carrying a suitcase, can become very difficult as the condition gradually worsens
COPD Diagnosis
"spirometry" COPD develops slowly, it is frequently diagnosed in people aged 40 or older COPD is not curable Various forms of treatment can help control its symptoms and increase quality of life for people with the illness. For example, medicines that help dilate major air passages of the lungs can improve shortness of breath
Introduction
major bearing on the risk factors for NCD The health sector however plays a role in advocacy and partnering with other sectors to effect change Actions must also utilise a life-course approach, starting with maternal health and pre-natal nutrition, pregnancy outcomes, exclusive breastfeeding, and child and adolescent health, reaches children at schools, adults at workplaces and other settings, and the elderly; and encourages a healthy diet and regular physical activity from young into old age
Introduction
Seven Strategies 1. Prevention and Promotion 2. Clinical Management 3. Increasing Patient Compliance
Introduction
incorporated into the Healthy Settings approach; this will include expanding the school health services to include nutrition and exercise promotion, cardiovascular risk and early intervention
whole-of-society response Political and community leadership, partnerships and community mobilisation are essential to ensuring acceptance and popular support for NCD prevention and control. Resources for prevention and control are limited; partnerships and collaboration can facilitate resource leveraging to augment national health budgets Furthermore, policy and population based interventions require the cooperation and acceptance of society
approaches to disease management For greatest utility, research communities and countries should utilize standardized methodologies, instruments, indicators, to permit comparisons and broad applicability of lessons learned
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