Bsc Nursing Part5

Epidemiology of Tetanus, Leprosy, HIV and other STD

Biju George

Tetanus • Neonatal tetanus and adult tetanus • Endemic in India. • Occasional cases in Kerala in unimmunized children • Clostridium tetani • Spores resistant to autoclaving • Germinate in anaerobic conditions • Exotoxin- tetano spasmin

Tetanus • Organism in soil and dust • Bacilli in intestine of many herbivorous animals like cattle, hoarse, goats, sheep. • excreted in feces. • In adults • Puerperal tetanus • Neonatal tetanus • More common in agricultural workers

Tetanus • • • • •

More in rural area. No herd immunity Surroundings play a role So cannot be eradicated But can be disease can be controlled and eliminated practically. • Contamination of wounds by spores • Toxin bind to receptors in nerve.

Tetanus • Incubation period – 6-10 days • Tetanus neonatorum - 8th day disease • Neonatal tetanus (NT) elimination • High risk – NT cases>1/1000 live births – Or TT2 coverage <70% – Or Attended deliveries- <50%

• Control – NT cases<1/1000 live births – And TT2 coverage >70% – And Attended deliveries- >50%

• Elimination – NT cases<1/10000 live births – And TT2 coverage >90% – And Attended deliveries- >75%

Tetanus • Active immunization-DPT/ DT / TT vaccine • Passive immunization TIG / ATS • Antibiotics -long acting penicillin/ erythromycin • Prevention of Neonatal tetanus – 5 cleans- hand, surface, blade, cord tie, cord – TT2 dozes in pregnancy – Attended Delivery / dhai training

• Prevention of tetanus after injury

Prevention of tetanus after injury • • • •

A- Complete course and booster with in last 5 yrs B-Complete course and booster between 5 - 10 yrs C-Complete course and booster more than 10 yrs No complete immunity / immunization unknown

wound <6 hrs, clean, small • A- nothing more • B- TT 1 doze • C- TT 1 doze • D- TT complete course

other wounds • A- nothing more • B- TT 1 doze • C- TT 1 doze + Hu Ig • D- TT complete course + Hu Ig

Leprosy • Characterized by cardinal features • Hypo-pigmented patches • Partial or total loss of cutaneous sensations (light touch) • Presence of thickened nerves • Presence of AFB in skin or nasal smears

Leprosy • • • • • • •

Advanced stage Nodes or lumps in skin of face / ears Plantar ulcers Loss of fingers / toes Nasal depression Foot drop Claw toes and other deformities

Leprosy • • • • • • • •

M. leprae Intracellular and extra cellular Affinity for schwann cells and cells of RES Max bacterial load in lepromatous cases Multi-bacillary cases are the important sources Nose is the major port of exit Ulcerated sin, broken skin 4-12% attack rate in house hold in 5 yrs

Leprosy • In endemic areas- infection in childhood itself. • 10-20 yrs • CMI plays an important role • High cell mediated immunity- Tuberculoid spectrum • Low CMI- lepromatous spectrum • Factors favoring close contact

Leprosy • • • •

Droplet transmission / contact 3-5 yrs incubation period Clinical classification Indian classification – Indeterminate / tuberculoid / boderline / lepromatous / pure neuritic

• Madrid classification – Indeterminate / tuberculoid / boderline / lepromatous

• Ridley Jopling classification – TT / BT / BB / BL / LL

Leprosy • Initially diagnosis as Paucibacillary / multi bacillary bases on Bacteriological index • Bactriological Index > 2 – multibacillary • Programmatically it is done on the basis of number of lesions • 1-5 skin lesion- pauci bacillary and / only one nerve lesions • More than 5 skin lesions- multibacillary and / have more than 2 nerve involvement

Leprosy • Lepromin test – 0.1 ml lepromin ID forearm • Early reaction- Fernandez reaction-read at 48 hrs red area >10 mm • Late reaction- Mitsuda reaction read at 21 daynodule more than 5 mm- CMI • Not diagnostic • Used for evaluating CMI in leprosy pts • Alternatively -Lymphocyte transformation test (LTT) and Leukocyte migration inhibition test (LMIT)

Leprosy - control • Medical measures – – – – – – – –

Estimation of problem – prevalence, ACDR Early case detection – skin lesion Multidrug therapy Surveillance of cases – 2 yrs / 5 yrs Immunoprophylaxis- BCG Chemoprophylaxis Deformity reduction Grade 0 / Grade I / grade II Rehabilitation

• Social support • Program management • Program evaluation

Leprosy • Multidrug Rx • Multibacillry leprosy – 12 months – Rifampacin 600 mg once monthly supervised – Dapsone 100 mg daily self administered – Clofazimine- 300 mg once monthly supervised and 50 mg daily self administered

• Paucibacillary leprosy – 6 months – Rifampacin 600 mg once monthly supervised – Dapsone 100 mg daily self administered

STD • Bacterial – – – –

Neisseria gonorrhea Chlamydia trachomatis Treponema pallidum Mycoplasma Hominis

• Viral – – – – – –

HSV (HHV-1 or 2) HHV-5- CMV Hepatitis B Human Papilloma virus Molluscum contagiosum virus HIV

STD • Protozoal – Entamoeba histolytica – Giardia lamblia – Trichomonas Vaginalis

• Fungal agents – Candida Albicans

• Ectoparasite – Phthirus pubis – Sarcoptis scabie

STD • Classical Venereal disease – Syphilis – Gonorrhea – Chancroid – Lymphogranuloma venereum – Donovanosis

• Second generation STD- HIV

STD • • • • • • • • •

N. Gonorrhoeae T. Pallidum H. Ducreyi Chlamatobactrrium granulomatis H. simplex HPV HIV Candida albicans Trichomonas Vaginalis

• • • • • • • • •

Gonorrhea Syphilis Chancroid Donovanosis (Granuloma inguinale) Genetal Herpes Genital and anal warts AIDS Vaginitis Vaginitis

STD • 20-24 age group then 25-29 yrs then 15-19 yrs • More men than females • Social factors – – – – – – – – – – –

Prostitution Broken homes Sexual disharmony Easy money Emotional immaturity Urbanization and industrialization Social disruption International travel Changing behavioral pattern Social stigma Alcoholism

STD • Gonococcal infection- Urethritis, vaginiyis, cervicitis • Syphilis- Ulceration of urogenital tract late stage complication • Chlamydial infection- Urethritis, vaginiyis, cervicitis • Trichomoniasis- vaginitis • Chancroid- genital ulcer + bubo • LGV- inguinal LN swelling

STD • Donovaniosis- granulomatous lesion • Syndromic approach – Male urthritis – Vaginitis / Cervicitis / Urethritis – Gentital ulceration – Proctitis / colitis – PID

Control of STD • Interventions – – – – –

Case detection Case holding and Treatment Epidemiological Rx- contact Rx Personal prophylaxis Health education

• Support service – – – – – –

STD clinics Lab services Primary health care Information services Legislation Social welfare measures

HIV / AIDS • world – ~40 million people with HIV – Every year ~4.5 million people get infected – ~3 million deaths every year

• India – ~1lak people with AIDS – ~5 million with HIV – ~0.36% prevalence

HIV / AIDS • Risk – Unprotected heterosexual route – MSM – Inj drug users – Unsafe blood transfusion – Unsafe injection

• Lag time from infection to symptoms 9-11 yrs

HIV / AIDS • • • • • • •

Mostly adults 20-50 yrs More mortality in females RNA virus Destroy the T4 helper cells Easily killed by heat and chemicals Cases are the reservoir /// carriers Source of infection – Blood, semen, CSF and other body fluids • Produce immune system disorder

HIV / AIDS • Person to person transmission – Sexual transmission • Presence of STD 8-10 times • Sex and age of uninfected partner • Virulence of HIV stain

– Blood contact BT-95% risk – parent to child transmission • 15-30% with our Rx • With Rx less than 5%

• Incubation period-10 yrs or more

HIV / AIDS • Clinical features – Initial infection • Window period- Ab after 2-12 wks

– Asymptomatic carrier state – AIDS related complex • Diarrhoea • Fever • Loss of wt

– AIDS • TB/ Kaposil sarcoma / candidiasis / CMV retinitis • Penumocystis carini infection / Toxoplasmosis

HIV control • Prevention – Education – Prevention of blood born HIV transmission

• Antiretroviral treatment – Rx of patients – Post exposure prophylaxis – PPCT

• Specific prophylaxis against opportunistic infection • Primary health care • NACP

Testing strategy- symptomatic-2

Testing strategy- asymptomatic-3