nursesrevision@gmail.com

Typhoid Fever (Enteric Fever)

Typhoid fever is an acute bacterial infection characterized by fever and is primarily spread through contaminated food and water.

Causes

Typhoid fever is caused by Salmonella typhi and Salmonella paratyphi A and B.

Transmission:

• Typhoid fever is contracted by the ingestion of the bacteria in contaminated food or water.
• Patients with acute illness can contaminate the surrounding water supply through stool, which contains a high concentration of the bacteria.
• About 3-5% of patients become carriers of the bacteria after the acute illness. Some patients suffer a very mild illness that goes unrecognized, and these patients can become long-term carriers of the bacteria.
• The bacteria multiply in the gallbladder, bile ducts, or liver and pass into the bowel.
• The bacteria can survive for weeks in water or dried sewage.
• The chronic carriers may have no symptoms and can be the source of new outbreaks of typhoid fever for many years.

Signs and Symptoms of Typhoid Fever

Classically, the course of untreated typhoid fever is divided into four stages, each lasting approximately one week.

First week:

• In the first week, there is a gradual rise in temperature (step-ladder fashion) accompanied by bradycardia, malaise, headache, generalized body aching, restlessness, and cough.
• Epistaxis (nosebleeds) is observed in about a quarter of cases.
• Abdominal pain may also be present.
• Leukopenia, eosinopenia, and relative lymphocytosis are evident in blood tests.
• The classic Widal test, used to detect antibodies against Salmonella, is negative in the first week, but blood culture reveals the presence of Salmonella typhi.
• The payer patches of the distal end of the ileum are invaded by the bacillus and become inflamed, resulting in various manifestations such as slow pulse rate, severe persistent frontal headache, general malaise, anorexia, nausea, vomiting, intestinal upset (diarrhea and constipation), and depression of bone marrow.

Second week:

• The payer patches form a slough (a layer of dead skin).
• In the second week of the infection, the patient becomes severely ill with high fever, often reaching around 40°C (104°F), and bradycardia.
• Delirium is common, characterized by a state of calmness or, at times, agitation.

• Rose spots, which are pink spots, appear on the lower chest and abdomen in about one-third of patients.
• The abdomen becomes distended and painful, especially in the right lower quadrant.
• Diarrhea may occur, with stool appearing green and having a characteristic smell resembling pea soup. However, constipation can also be frequent.
• The spleen and liver enlarge (hepatosplenomegaly) and become tender.
• The Widal reaction shows strong positivity with anti-O and anti-H antibodies, while blood cultures may still be positive at this stage.
• The tongue is coated with a brownish fur, and sordes indicate severe toxemia.
• Dehydration becomes evident.

Third week:

• In the third week of typhoid fever, several complications may arise:
  • The slough separates, leaving deep ulcers in the intestines.
  • Ulcers may erode blood vessels, leading to hemorrhage, or perforate the ileum, causing leakage of intestinal contents into the peritoneal cavity.
  • The patient becomes extremely ill and toxic.
  • Temperature remains very high and intermittent.
  • Pulse becomes feeble.
  • The patient lapses into a typhoid state, experiencing delirium and confusion.
  • Twitching of limbs may occur due to loss of calcium in the diarrhea state.
  • Carforragic picking may lead to clotting issues and blood-stained clothes.
  • Tough dries and flurried lips are observed due to severe dehydration from profuse diarrhea.
  • Signs of congestive cardiac failure (CCF) due to weakened myocardium may be present.
  • The patient may experience coma every eight hours.
  • Peritonitis, inflammation of the peritoneum, may occur.
• By the end of the third week, the patient becomes emaciated, fever starts to subside, abdominal symptoms become more pronounced, and mental disturbances become prominent.

Fourth week:

• The ulcers begin to heal through granulation.
• At the beginning of the fourth week, the fever begins to decline, and the other symptoms gradually reduce as the patient\’s temperature returns to normal.
• Recovery is slow during this stage, and relapses are common.
• If left untreated, typhoid fever can prove fatal in up to 25% of all cases.

Investigations for Typhoid Fever:

1. Stool Culture: Stool culture involves collecting a sample of the patient\’s stool and incubating it under specific conditions to identify and isolate the causative bacteria, usually Salmonella typhi or Salmonella paratyphi. The presence of these bacteria in the stool confirms the diagnosis of typhoid fever. 

2. Blood Culture:  Blood sample is collected and cultured in a suitable medium to identify and isolate the bacteria causing typhoid fever. A blood culture is an effective method to confirm the diagnosis, especially in the early stages of the disease when stool cultures might be negative.

3. Widal Test: The Widal test is a serological test used to detect antibodies produced by the body in response to the infection by Salmonella typhi. The test measures the presence of specific antibodies, including anti-O and anti-H antibodies, in the patient\’s blood. A positive Widal test suggests a recent or past infection with typhoid fever. However, it is important to note that the Widal test results should be interpreted cautiously, as false-positive results can occur due to cross-reactivity with other infections or previous vaccinations.

Additional Investigations (optional):

1. Polymerase Chain Reaction (PCR) Test: PCR is a molecular diagnostic test that can detect the genetic material (DNA or RNA) of the Salmonella bacteria directly from clinical samples, such as blood or stool. PCR is a highly sensitive and specific method, and it can provide rapid results, aiding in early detection and timely treatment of typhoid fever.

2. Typhoid Serology: Typhoid serology involves analyzing the patient\’s blood for specific antibodies against Salmonella typhi. This test, similar to the Widal test, helps in confirming a recent or past infection, but it may have limitations in terms of sensitivity and specificity.

3. Complete Blood Count (CBC): A CBC is a routine blood test that provides information about the number and types of blood cells. In typhoid fever, the CBC may show leucopenia (low white blood cell count), eosinopenia (low eosinophil count), and relative lymphocytosis (increased lymphocyte percentage). These abnormalities can help in supporting the diagnosis of typhoid fever.

4. Liver Function Tests (LFTs): Liver function tests assess the health of the liver and its ability to function properly. In typhoid fever, liver involvement is common, and LFTs can reveal elevated liver enzymes and other liver-related abnormalities.

5. Urinalysis: Urinalysis may be performed to check for the presence of white blood cells or other indicators of kidney involvement, which can occur in severe cases of typhoid fever.

Complications of Typhoid Fever:

I. Gastrointestinal Complications:
A. Perforation: The ulcerated areas in the intestines can lead to perforation, causing leakage of intestinal contents into the abdominal cavity. This can result in severe abdominal pain and peritonitis.
B. Hemorrhage: The erosion of blood vessels by ulcers can cause gastrointestinal bleeding, leading to blood loss and anemia.
C. Peritonitis: Perforation of the intestine can lead to peritonitis, an inflammation of the peritoneum (the lining of the abdominal cavity), causing severe abdominal pain and tenderness.

II. Gallbladder Complications:
A. Cholecystitis: The infection can spread to the gallbladder, causing inflammation known as cholecystitis, which leads to abdominal pain, fever, and tenderness in the right upper abdomen.

III. Respiratory Complications:
A. Pneumonia: In severe cases, typhoid fever can lead to pneumonia, a lung infection characterized by fever, cough, and difficulty breathing.

IV. Cardiovascular Complications:
A. Heart Failure: Severe and untreated typhoid fever can put a strain on the heart, leading to congestive heart failure, a condition where the heart fails to pump blood effectively, resulting in fluid accumulation in the body.

V. Musculoskeletal Complications:
A. Osteomyelitis: In rare cases, typhoid fever bacteria can spread to the bones, causing osteomyelitis, which is an infection of the bone and bone marrow.

VI. Neurological Complications:
A. Encephalitis: Typhoid fever can lead to encephalitis, which is inflammation of the brain. This can cause symptoms such as headache, confusion, and altered mental state.

B. Meningitis: In some instances, the infection may also spread to the meninges, the protective membranes covering the brain and spinal cord, leading to meningitis. 

C. Mental Confusion: During the advanced stages of the disease, mental confusion and delirium may occur due to the systemic effects of the infection on the central nervous system.

Management of Typhoid Fever

1. Hospital Admission:

• In severe cases of typhoid fever, hospital admission is necessary to provide close monitoring and appropriate medical care.

1. Isolation or Barrier Nursing:

• Patients with typhoid fever should be isolated or barrier nursed to prevent the spread of the infection to others.

1. Investigations:

• Blood for Culture and Sensitivity (C/S) should be performed during the first week to identify the causative bacteria and determine its sensitivity to antibiotics.
• Full Blood Sample (FBS) analysis will reveal low Hemoglobin (Hb) levels, low White Blood Cell (WBC) count, and an increased Erythrocyte Sedimentation Rate (ESR).
• The Widal test can be done around 10/7 days after the onset of symptoms to detect antibodies against typhoid bacilli.
• Blood Smear (B/S) examination should be conducted to rule out malaria.
• Stool analysis and urinalysis are important to assess gastrointestinal and urinary involvement in typhoid fever.

1. Drug Therapy:

• Antibiotic therapy is a cornerstone of typhoid fever management:
  • Ciprofloxacin at a dose of 500-750 mg twice daily for 10/7 (10 days).
  • Azithromycin at a dose of 10 mg/kg daily.
  • Cotrimoxazole at a dose of 960 mg twice daily for 3/7 (3 days) or as per a weight-based calculation for 10/7 (10 days).

1. Long-Term Carriers:

• After signs have passed, stool tests should be conducted to check if Salmonella typhi bacilli are still present. Patients may become potential long-term carriers of the bacteria, requiring a 28-day course of antibiotics to eliminate the bacteria until they are free from it.

1. Fluid and Electrolyte Management:

• Monitor intravenous (IV) fluid administration for rehydration.
• Correct fluid and electrolyte imbalances with Normal Saline (N/S), Dextrose 5% (D5%) solutions, and oral fluids.

1. Nutrition:

• Ensure adequate nutrition and provide a soft, easily digestible diet, unless the patient has abdominal complications or ileus.

1. Antipyretics:

• Administer antipyretics like Paracetamol (PCM) to manage fever.

1. Hygiene and Infection Control:

• Pay close attention to handwashing and limit close contact with individuals during the acute phase of the infection to prevent its spread.
• Encourage proper waste disposal, covering of food, and proper food preparation to reduce contamination risks.
• Encourage early screening and management to prevent the worsening of the disease.

1. Proper Water Treatment and Storage:

• Educate patients on the proper treatment and storage of water to avoid waterborne transmission of the bacteria.

1. Regular Follow-Up and Monitoring:

• Ensure regular follow-up and monitor for complications and clinical relapses.

1. Management of Delirium:

• Encourage the use of Phenobarbital at a dose of 30-60 mg in case of delirium.

Prevention:

• Maintain cleanliness in the premises and ensure proper disposal of rubbish.
• Keep hands clean and maintain trimmed fingernails.
• Wash hands thoroughly with soap and water before eating or handling food and after using the toilet or changing diapers.
• Drinking water should be free from microorganisms; it is preferable to boil water before consumption.
• Avoid high-risk foods, such as raw or semi-cooked food.
• During food preparation, wear clean, washable aprons, and caps.
• Clean and wash food thoroughly, including scrubbing and rinsing fruits in clean water.
• Store perishable food in the refrigerator, covering it properly.
• Cook food thoroughly before consumption.
• Consume food as soon as it is prepared.
• If necessary, refrigerate cooked leftover food and consume it promptly. Reheat it thoroughly before consumption.
• Exclude infected individuals and asymptomatic carriers from handling food and providing care to children.
• Consider immunization, especially for those traveling to high-risk areas, where vaccines are available in oral and injectable forms.

Test MCQ Questions

Question 1:
What is the primary mode of transmission for typhoid fever?
A) Mosquito bites
B) Contaminated food and water
C) Airborne droplets
D) Direct physical contact

Question 2:
Which bacterium is responsible for causing typhoid fever?
A) Escherichia coli
B) Salmonella typhi
C) Streptococcus pneumoniae
D) Staphylococcus aureus

Question 3:
Which of the following complications can occur in severe cases of typhoid fever?
A) Fractures
B) Renal failure
C) Dental caries
D) Cholecystitis

Question 4:
Which diagnostic test is used to identify the presence of Salmonella typhi in the blood?
A) Blood smear examination
B) Stool culture
C) Urinalysis
D) Blood culture

Question 5:
What is the recommended antibiotic therapy for treating typhoid fever?
A) Penicillin
B) Amoxicillin
C) Ciprofloxacin
D) Erythromycin

Question 6:
Why is hospital admission often recommended in severe cases of typhoid fever?
A) To provide psychological support to the patient
B) To administer vaccines for long-term immunity
C) To ensure isolation and prevent disease transmission
D) To allow close monitoring and provide appropriate medical care

Question 7:
What is the primary preventive measure to avoid typhoid fever transmission in the community?
A) Proper handwashing with soap and water
B) Mosquito net usage
C) Wearing masks in public places
D) Vaccination against other bacterial infections

Question 8:
Which gastrointestinal complication can occur due to typhoid fever?
A) Pneumonia
B) Peritonitis
C) Otitis media
D) Conjunctivitis

Question 9:
Which of the following is NOT a recommended step to prevent typhoid fever?
A) Drinking untreated water from natural sources
B) Cooking food thoroughly
C) Washing hands properly before eating
D) Proper waste disposal

Question 10:
Who should be excluded from handling food and providing care to children during a typhoid fever outbreak?
A) Asymptomatic carriers and infected individuals
B) Healthcare professionals only
C) Pregnant women
D) Children under 5 years of age

Answers:

1. B – Contaminated food and water
2. B – Salmonella typhi
3. D – Cholecystitis
4. D – Blood culture
5. C – Ciprofloxacin
6. D – To allow close monitoring and provide appropriate medical care
7. A – Proper handwashing with soap and water
8. B – Peritonitis
9. A – Drinking untreated water from natural sources
10. A – Asymptomatic carriers and infected individuals

Explanation:

1. Typhoid fever is primarily spread through contaminated food and water, making option B the correct answer.
2. Salmonella typhi is the bacterium responsible for causing typhoid fever, making option B the correct answer.
3. Cholecystitis is one of the gastrointestinal complications associated with typhoid fever, making option D the correct answer.
4. Blood culture is used to identify the presence of Salmonella typhi in the blood, making option D the correct answer.
5. Ciprofloxacin is one of the recommended antibiotics for treating typhoid fever, making option C the correct answer.
6. Hospital admission is recommended in severe cases of typhoid fever for close monitoring and appropriate medical care, making option D the correct answer.
7. Proper handwashing with soap and water is the primary preventive measure to avoid typhoid fever transmission, making option A the correct answer.
8. Peritonitis is a gastrointestinal complication that can occur due to typhoid fever, making option B the correct answer.
9. Drinking untreated water from natural sources is NOT a recommended step to prevent typhoid fever, making option A the correct answer.
10. Asymptomatic carriers and infected individuals should be excluded from handling food and providing care to children during a typhoid fever outbreak, making option A the correct answer.

Bacillary Dysentery (Shigellosis):

Bacillary dysentery is an acute bacterial disease that primarily affects the large and small intestine, leading to symptoms such as bloody mucoid diarrhea.

 It is important not to confuse bacillary dysentery with diarrhea caused by other bacterial infections, as one of the distinguishing characteristics of bacillary dysentery is the presence of blood in the stool, resulting from the invasion of the pathogen into the mucosa.

Cause:

• • Bacillary dysentery is caused by different types of Shigella bacteria, including Shigella sonnei, Shigella flexneri, and Shigella dysenteriae.

Mode of Transmission:

• • Bacillary dysentery can be transmitted directly through fecal material of a patient or carrier.
  • It can also be transmitted indirectly through contaminated food and water.
  • Infection can occur even after consuming a small number of bacteria, making household spread and transmission in institutions highly likely.
  • Young children are particularly susceptible to this infection.

Clinical Features:

• • Incubation period: 1-3 days (can extend up to 7 days).
  • Common symptoms include:
    • Sudden onset of mucoid bloody diarrhea.
    • Fever.
    • Nausea and vomiting.
    • Abdominal cramps.
    • Tenesmus (sensation of desire to defecate without producing significant amounts of feces).
    • Flatulence.
    • Headache and fatigue.
    • Dehydration.

Diagnosis:

• • Fresh stool samples are collected for culture and sensitivity testing, as well as microscopy to identify the causative bacteria.

Management:

• • Admission to a medical ward in isolation.
  • Strict personal hygiene (barrier nursing) to prevent infecting others.
  • Disinfection of the patient\’s bed and other items used.
  • Proper disposal of fecal matter and vomit into a pit latrine.
  • Regular monitoring of temperature, pulse, respiration, blood pressure, hydration levels, and level of consciousness.
  • Providing reassurance and support to the patient and relatives.
  • Fluid intake maintenance using Oral Rehydration Solution (ORS) or intravenous fluids in severe cases.
  • Antibiotic treatment with drugs like nalidixic acid or ciprofloxacin.
  • Implementing a BRAT diet (bananas, rice, applesauce, toast) to aid in recovery.
  • Use of a nasogastric tube for feeding and medication administration if oral intake is not possible.
  • Medications for managing nausea and vomiting, such as metoclopramide (plasil).
  • Close monitoring of hydration levels and maintenance of a fluid balance chart.

Prevention:

• • Maintain cleanliness in premises and kitchen utensils.
  • Proper disposal of rubbish.
  • Practice proper hand hygiene before eating or handling food, and after using the toilet or changing diapers.
  • Boil or treat drinking water.
  • Avoid high-risk foods like shellfish, raw or semi-cooked food.
  • Use clean washable aprons and caps during food preparation.
  • Thoroughly clean and wash food items, including fruits, in clean water.
  • Store perishable food in a well-covered refrigerator.
  • Ensure thorough cooking of food before consumption.
  • Consume food promptly or refrigerate leftovers and reheat thoroughly before eating.
  • Exclude infected individuals and asymptomatic carriers from handling food or providing care to children.

Amoebic Dysentery (Amoebiasis)

Amoebic dysentery is a parasitic infection of the gastrointestinal system that is caused by the parasite Entamoeba histolytica. 

The infection is most commonly acquired through oral-fecal contamination, which can occur by consuming contaminated food or water, or by coming into contact with contaminated feces and not washing your hands properly.

Symptoms of amoebic dysentery 

• Violent diarrhea, often with blood and/or mucus in the stools
• Severe colitis
• Frequent flatulence
• Dehydration
• Abdominal cramps and tenderness
• Slight weight loss
• Moderate anemia
• Moderate fever
• Mild fatigue
• Unrelated symptoms such as liver abscess, lung involvement, amoeboma swelling, and anal ulceration

Diagnosis

The diagnosis of amoebic dysentery is usually made by examining a stool sample under a microscope to look for cysts or motile organisms. Ultrasound scans may also be performed.

Treatment

The treatment of amoebic dysentery involves several steps:

1. Correcting any dehydration
2. Initiating a 10-day course of the antimicrobial drug metronidazole (Flagyl) or tinidazole to eliminate the infection
3. Administering amoebicidal (lumenal) drugs such as diloxanide furoate, paromomycin, or iodoquinol to eradicate any remaining parasites
4. Isolating infected individuals to prevent further spread of the infection
5. Emphasizing personal hygiene practices

Prevention

To prevent the occurrence and transmission of amoebic dysentery, the following preventive measures should be followed:

• Educate the public about proper handwashing before eating and appropriate fecal disposal practices.
• Ensure the proper management of carriers of the infection.
• Promote the use of clean drinking water and safe food handling practices.

Cholera

Cholera is an infection of the small intestine caused by the bacterium Vibrio cholerae.

The infection is characterized by profuse watery stools, vomiting, dehydration, and collapse. 

Cause

• Cholera is specifically caused by the bacterium Vibrio cholerae.

This bacterium is Gram stain negative and possesses a flagellum, a long projecting part that enables it to move, and pili, hair-like structures that it uses to attach to the intestinal tissue.

Transmission

• The primary mode of transmission for cholera is through the fecal contamination of food and water, often resulting from poor sanitation practices. When individuals infected with cholera have untreated diarrheal discharge, the bacteria can enter waterways or drinking water supplies, contaminating them.
• Consuming food that has been washed in contaminated water can also lead to transmission. It is important to note that cholera is rarely spread directly from person to person.

Susceptibility: Several factors influence the susceptibility to cholera:

1. Ingestion of bacteria: In a normal, healthy adult, approximately 100 million bacteria must typically be ingested to cause cholera. This highlights the importance of a significant bacterial load for infection to occur.

2. Age: Children, particularly those between the ages of two and four, are more susceptible to cholera infection. This could be attributed to their underdeveloped immune systems and increased likelihood of exposure due to their behavior and hygiene practices.

3. Lowered immunity: Individuals with weakened immune systems, such as those with AIDS or malnourished children, are at higher risk of experiencing severe cases if they become infected with cholera. Their compromised immune function makes it more difficult for their bodies to fight off the infection effectively.

Pathophysiology of Cholera

Cholera is a gastrointestinal illness caused by the bacterium Vibrio cholerae. The bacteria produce a toxin that causes the body to lose water and electrolytes, leading to severe diarrhea.

How the Bacteria Enter the Body

Most Vibrio cholerae bacteria are killed by the acidic environment of the stomach. However, a small number of bacteria can survive and travel to the small intestine. The bacteria attach to the intestinal wall and produce a toxin that causes the body to lose water and electrolytes.

The Toxin

The toxin produced by Vibrio cholerae is called cholera enterotoxin. The toxin binds to cells in the small intestine and activates an enzyme that causes the cells to pump water and electrolytes into the intestine. This results in the production of large amounts of watery diarrhea.

More Detailed Pathophysiology:
Upon consumption, most Vibrio cholerae bacteria do not survive the acidic conditions of the human stomach. However, a small number of bacteria manage to survive. As they exit the stomach and reach the small intestine, they need to navigate through the thick mucus lining in order to reach the intestinal walls, where they can establish themselves and multiply. Vibrio cholerae bacteria possess flagella for mobility and pili to attach to the intestinal tissue.

Vibrio cholerae bacteria produce a toxin that is responsible for causing the most severe symptoms of cholera. This toxin, known as an enterotoxin, acts on human cells, prompting them to extract water and electrolytes from the body, primarily from the upper gastrointestinal tract. The extracted fluid and electrolytes are then pumped into the intestinal lumen, resulting in the excretion of diarrheal fluid.

Signs and Symptoms

The incubation period for cholera is typically 2-3 days. The first signs and symptoms of cholera are watery diarrhea and vomiting. The diarrhea can be so profuse that it can lead to dehydration and shock.

In a typical case of severe cholera, the disease progresses through three stages:

Stage I:

• Profuse watery stools are expelled by the patient. Over time, fecal matter becomes nearly clear fluid with mucous flakes, giving it the characteristic \”rice-water\” appearance.
• Vomiting occurs, initially expelling food and later becoming restricted to rice-water-like fluid.
• Severe cramps develop in the abdomen and limbs due to salt loss.

Stage II:

• Dehydration and collapse occur during this stage.
• The body becomes cold, and the skin appears dry and inelastic.
• Blood pressure drops, sometimes becoming unrecordable.
• The pulse becomes rapid and weak.
• Urine production stops, and the patient may be at risk of shock.

Stage III:

• This stage marks the recovery phase, which can happen spontaneously or with treatment.
• Diarrhea decreases, allowing the patient to tolerate fluids.
• The general condition of the patient rapidly improves.

Diagnosis of Cholera

The diagnosis of cholera is based on the following:

• History: The patient may have a history of travel to an area where cholera is common, or they may have been in contact with someone who has cholera.
• Symptoms: The patient will typically have watery diarrhea and vomiting. The diarrhea may be so profuse that it can lead to dehydration and shock.
• Physical examination: The doctor will examine the patient for signs of dehydration, such as dry skin, sunken eyes, and decreased urination.
• Laboratory tests: The following laboratory tests may be performed to diagnose cholera:
  • Stool culture: This test is used to grow the bacteria in the laboratory.
  • Polymerase chain reaction (PCR): This test is used to detect the genetic material of the bacteria.
  • Rapid diagnostic test (RDT): This test is a rapid way to detect the bacteria.

Prevention of Cholera

Cholera is a serious disease that can be fatal, but it is preventable. The best way to prevent cholera is to follow proper sanitation practices.

Here are some specific steps you can take to prevent cholera:

1. Hand hygiene: Always wash hands with water and soap before preparing, serving, or consuming food. Additionally, it is important to wash hands with soap and water after using a latrine.

2. Safe drinking water: Boil all drinking water or treat it with chlorine. Store the treated water in a clean container to prevent recontamination.

3. Food safety: Consume food when it is still hot. If consuming raw foods such as fruits and vegetables, ensure they are properly washed, and when possible, peeled before eating.

4. Food storage: Cover all foods to prevent contamination by dust, house flies, and cockroaches.

5. Reporting and burial practices: In the unfortunate event of a cholera-related death, report it immediately to health authorities. Burial should take place promptly, and it is crucial to avoid serving food during this time.

6. Surveillance and reporting: Active surveillance and prompt reporting of suspected cases allow for the rapid containment of cholera epidemics.

7. Disinfection: Kill the germs by sprinkling germ-killing solutions, such as JIK, on stool or vomitus, as well as on any other materials used by the person suffering from cholera.

8. Water and sanitation improvement: Enhance water and sanitation infrastructure to reduce the transmission of infection, such as by improving access to clean water sources and implementing proper waste management systems.

9. Outbreak investigations: Conduct thorough investigations of diarrheal outbreaks to identify the source of contamination and implement appropriate control measures.

10. Cholera vaccination: Consider immunization with cholera vaccines in areas prone to outbreaks or for individuals at high risk of exposure.

11. Treatment of malnutrition: Address malnutrition, as individuals with weakened immune systems are more susceptible to severe cholera. Providing adequate nutrition can help improve their overall resilience.

Management and Treatment

1. Patient admission: The patient can be admitted to temporary hospitals, schools, or churches. Cholera beds with a central hole are used, allowing continuous stools to pass into a calibrated bucket containing a disinfectant.

2. Oral Rehydration Solution (ORS): ORS is the primary treatment for cholera. It is recommended for rehydrating patients and replenishing electrolytes lost through diarrhea. In cases of severe dehydration, intravenous Ringer\’s lactate or normal saline, along with ORS, may be administered. The patient should be reassessed every one to two hours, and hydration should be continued. If there is no improvement in hydration, the intravenous drip rate may be increased. During the first 24 hours of treatment, the patient may require 200ml/kg or more of fluid. If hydration improves and the patient is able to drink, switching to ORS solution is recommended.

3. Nasogastric tube: In young children, a nasogastric tube can be used to administer fluids if necessary, ensuring adequate hydration.

4. Antibiotics: In certain cases, antibiotics may be prescribed. Doxycycline 300mg or ciprofloxacin as a single dose can be given, but they are contraindicated in pregnancy. For pregnant women, septrin can be used. In children, cotrimoxazole, doxycycline, ciprofloxacin, or erythromycin may be considered based on the specific circumstances.

5. Hypoglycemia management: If hypoglycemia is present, intravenous dextrose should be administered to correct low blood sugar levels.

6. Zinc supplementation: Zinc supplementation is effective in treating and preventing diarrhea, especially among children. It can be provided to aid in recovery.

7. Isolation and infection control: Patients should be isolated to prevent the spread of infection, as stools and vomit are highly infectious. Proper disposal of stools and vomit should be carried out, preferably into a pit latrine.

8. Equipment and instrument disinfection: Hospital equipment should be cleaned with a disinfectant such as JIK. Instruments can be cleaned with JIK or sterilized to prevent the transmission of the infection.

9. Fluid balance chart: A fluid balance chart should be instituted to monitor the patient\’s hydration status closely.

Complications

• Shock
• Electrolyte imbalance
• Acute renal failure
• Convulsions/Fits
• Anaemia
• Coma

Related Question

a) List 5 cardinal signs and symptoms of cholera.

b) Outline 10 specific nursing care in an outbreak of cholera.

Solutions

a) Five cardinal signs and symptoms of cholera include:

1. Watery diarrhea, sometimes in large volumes.
2. Nausea and vomiting.
3. Dehydration.
4. Rice-water stools.
5. Loss of skin elasticity.

b) Ten specific nursing care measures in an outbreak of cholera:

1. Wash hands with soap and running water frequently, especially after using the toilet and before handling food.
2. Advise people to drink only safe water, such as bottled water or water that has been boiled.
3. Encourage individuals to consume food that is fully cooked and hot, and to avoid street vendor food whenever possible.
4. Discourage the consumption of sushi, as well as raw or improperly cooked fish and seafood.
5. Monitor intake and output, taking note of the number, character, and amount of stools.
6. Promote the use of latrines or proper disposal of feces, emphasizing not to defecate in any body of water.
7. Ensure that any articles used are properly disinfected or sterilized before use.
8. Maintain strict asepsis during dressing changes, wound care, intravenous therapy, and catheter handling.
9. Practice hand hygiene by washing hands or using hand sanitizer before and after having contact with the patient.
10. Implement proper waste management procedures, particularly for human excreta.

Gastroenteritis (GE)

Gastroenteritis is a medical condition characterized by inflammation of the gastrointestinal tract that involves both the stomach (\”gastro\”-) and the small intestine (\”entero\”-), resulting in some  combination of diarrhea, vomiting, and abdominal pain and cramping.  

The severity of infectious gastroenteritis depends on the immune system’s ability to resist the  infection.  

Electrolytes (mainly sodium and potassium) may be lost as the infected individual vomits and  experiences diarrhea.  

Causes of Gastroenteritis

1. Viruses 

•  Rotavirus, norovirus, adenovirus, and astrovirus are known to cause viral gastroenteritis. 
•  Rotavirus is the most common cause of gastroenteritis in children. 
•  Norovirus  is the leading cause of gastroenteritis among adults, causing greater than 90%  of outbreaks.

1. Bacteria 

• In the developed world Campylobacter jejuni is the primary cause of bacterial GE. 
• Escherichia coli 
•  Salmonella, Shigella, and Campylobacter species. 
• Salmonella is contracted by ingesting the bacteria in contaminated food or water and by  handling poultry. 
• Campylobacter occurs by the consumption of raw or undercooked poultry meat and other  foods. It is also associated with unpasteurized milk or contaminated water.  
• Clostridium difficile is an important cause of diarrhea that occurs more often in the elderly. It is a common cause of diarrhea in those who are hospitalized and is frequently  associated with antibiotic use. 
•  Staphylococcus aureus infectious diarrhea may also occur in those who have used  antibiotics. 

1. Parasites 

A number of protozoans can cause gastroenteritis – most commonly: – Giardia lamblia 

• – Entamoeba histolytica 
• – Cryptosporidium 

1. Non-infectious causes 

• – Medications like NSAIDs 
• – Certain foods such as lactose (in those who are intolerant). 
• – Crohn\’s disease.

Transmission:

The transmission of germs occurs through the feces or vomit of individuals infected with the illness. Gastroenteritis can be spread through the following means:

• Consuming untreated or unboiled water from rivers, streams, lakes, ponds, or unprotected springs.
• Eating cold food that has been exposed to dust, flies, or cockroaches.
• Neglecting to wash hands with soap and water after using a latrine.
• Eating unwashed fruits and vegetables.
• Serving food and drinks in dirty containers.
• Storing drinking water in unclean containers.
• Improper disposal of feces.
• Presence of open rubbish in areas that attract flies and cockroaches.

Signs and Symptoms:

The primary symptom is diarrhea, often accompanied by vomiting. Infected individuals may notice the presence of blood or mucus in their stools. Crampy abdominal pain is a common occurrence, which may temporarily ease after passing stool. There may be a low-grade fever, headache, and body aches. Symptoms of dehydration may include:

• Muscular cramps, sunken eyes, decreased urine output, dry mouth and tongue, weakness, and irritability. In severe cases, adults may experience symptoms such as fatigue, dizziness or lightheadedness, headache, weakness, confusion, rapid heart rate, coma, and significantly reduced urine production.

Diagnosis:

• Gastroenteritis is diagnosed clinically, based on a person\’s signs and symptoms.
• Stool cultures should be performed especially in those with blood in the stool.

Management:

• Gastroenteritis is usually an acute and self-limiting disease that does not require medication.
• The preferred treatment in those with mild to moderate dehydration is oral rehydration therapy (ORT).
• Intravenous delivery may be required if there is a decreased level of consciousness or if dehydration is severe.
• Plain water may be used if more specific and effective ORT preparations are unavailable or not palatable.
• A nasogastric tube can be used in young children to administer fluids if necessary.
• Institute a fluid balance chart.
• Metoclopramide may be helpful in some children, and butylscopolamine is useful in treating abdominal pain.
• Fermented milk products (such as yogurt) are similarly beneficial.
• Zinc supplementation is effective in both treating and preventing diarrhea among children.
• Antibiotics are not usually used for gastroenteritis, although they are sometimes recommended if symptoms are particularly severe or if a susceptible bacterial cause is isolated or suspected.
  • If antibiotics are to be employed, a macrolide (such as azithromycin) is preferred. Metronidazole or Tinidazole is used if the cause is protozoa.
• Isolation of the patient to prevent cross-infection.
• Proper disinfection and disposal of stool and vomit.

Prevention and Control:

• Always wash hands with water and soap before preparing, serving, or eating food.
• Always wash hands with soap and water after using a latrine.
• Boil all drinking water or treat it with chlorine. Store it in a clean container.
• Consume food while it is still hot.
• Ensure that raw foods such as fruits and vegetables are properly washed and, whenever possible, peeled before eating.
• Cover all foods to prevent contamination by dust, house flies, and cockroaches.
• In the event of a person\’s death due to diarrhea, report it immediately to the health authorities.
• Kill germs by using germ-killing solutions like JIK (bleach) on stool or vomit and on all other materials used by the person suffering from diarrhea.
• Improve water and sanitation to reduce the transmission of infection.
• Conduct investigations of diarrheal outbreaks.
• Treat other infections such as typhoid, dysentery, etc.
• Address and treat malnutrition.
• Consider immunization with Rota vaccine, which provides protection against rotavirus, a common cause of gastroenteritis.

Introduction to communicable diseases

Communicable diseases, also known as infectious diseases or transmissible diseases are diseases  that spreads from one person or animal to another or from a surface to a person. 

Communicable diseases occur at all age groups outmost serious in childhood due to intensive exposure and poorly developed immunity. These diseases are to a great extent preventable

In countries where the disease have been largely prevented, other conditions like accidents, and degenerative and malignant diseases that occur at an old age have become the commonest, the process known as epidemiological transmission

Tropical countries, Uganda, inclusive have continued to struggle with poverty related diseases that occur at an old age which include: diarrhea, parasite infestations, respiratory infections, immunizable childhood infections, eye infections and malnutrition. These countries are at the same time facing steady increase of diabetes, CVA, rheumatic conditions and cancer

Communicable’ diseases are divided into 

• Contact contagious diseases
• STDs and HIV/AIDs
• Vector borne diseases
• Diseases related to contaminated water and food
• Airborne diseases
• Blood borne diseases
• Diseases from the animals and their products
• Helminthic diseases

Some Communicable diseases and there causative agents.

Causative Organism	Disease/Infection
Rabies virus	Rabies
Influenza A virus	Avian influenza (Bird flu)
Vibrio cholerae	Cholera
Plasmodium species	Malaria
Severe acute respiratory syndrome coronavirus (SARS-CoV)	Severe acute respiratory syndrome (SARS)
Trypanosoma species	Trypanosomiasis
Tsetse fly	Sleeping sickness (African trypanosomiasis)
Wuchereria bancrofti	Elephantiasis
Dracunculus medinensis	Guinea worm disease
Rotavirus	Diarrhea (caused by rotavirus)
Mumps virus	Mumps
Human immunodeficiency virus (HIV)	HIV/AIDS
Varicella-zoster virus	Chickenpox
Measles virus	Measles
Yellow fever virus	Yellow fever
Arboviruses	Arboviral diseases
African swine fever virus	African swine fever
Brucella species	Brucellosis
Salmonella enterica serovar Typhi	Typhoid fever
Schistosoma species	Schistosomiasis
Poliovirus	Poliomyelitis
Shigella species	Dysentery
Bacillus anthracis	Anthrax

Why are communicable diseases important in Africa?  

1. Many of them are very common 
2. Some of them are very serious and cause death and disability 
3. Some of them cause widespread outbreaks of the disease- epidemics 4. Many of them are preventable by fairly simple means 
4. Many are particularly serious and more common in infants and children. 

Organisms and agents of disease 

The living organisms that cause communicable diseases are of different sizes and sorts. The largest, like tape or filarial worms are visible to the eyes. They are made of many cells and  are called metazoa.  

Complicated but single celled organisms like malaria parasites and amoeba are called protozoa.  They are smaller and can only be seen when magnified with a microscope. Smaller still are bacteria which are simple, single cell, best seen under a microscope after they  have been stained with dyes. 

Rickettsiae and chlamydiae are smaller and can only multiply within cells. Smallest of all are the viruses. These cannot be seen with an ordinary microscope.

Epidemiological Triad

Patterns of communicable diseases 

Different diseases are common in different places and different times. To understand why this  happens we need to consider the living organisms of disease- the agent; the people they infect the host and the surrounding in which they live- the environment. 

The agents need a suitable environment in which to grow and multiply and must be able to  spread and infect other hosts. If they do not succeed in doing this, they die out.

There is therefore a balance between the agent, the host and the environment which can change  and be made to change in different ways.

Hosts (people) are affected by environment, for example, they may live in a hot climate in which  there many mosquitoes. But people can also change this environment by draining swamps,  changing the vegetation and adding competing hosts such as animals. 

Similarly, the environment can affect the agent, for example, the altitude and the temperature  for malaria. 

Terminology 

Infectious disease 

An infectious disease is an illness due to a specific infectious agent or its toxic products that arise  through a transmission of that agent or its products from an infected person, animal or reservoir  to a susceptible host, either directly through an intermediate plant or animal host, vector or inanimate environment. 

Infection 

Infection is the entry and development of an infectious agent in the body accompanied by an  immune response. 

Disease 

Manifestation of infection through symptoms and signs 

Exposed 

Someone who has met with an infectious agent in a way that is known to cause disease 

Colonization 

Colonization is the presence of a replicating microorganism without clinical or subclinical  infection or disease. No immune response. 

Carrier 

Carrier is a person that harbours a specific infectious agent in the absence of clinical disease and  serves as a potential source of infection.

Reservoir 

The reservoir of infection is the animal or place in which a particular organism usually lives and  multiplies. Most of the important communicable diseases humans are the main reservoirs. 

Route of transmission 

The route of transmission is the way in which an organism leaves the infected host or source and  travels to a new susceptible person. 

Source  

The source of infection is the animal or place from which the particular organism spreads to its  new host. 

Incubation period 

The incubation period is the time between infection and the appearance of signs and symptoms  of illness. 

Epidemiology 

Epidemiology is the study of the distribution and patterns of health events, health characteristics  and their causes or influences in a well defined population. Or 

It is a branch of medicine that deals with the study of the causes, distribution and control of  diseases in the population. 

Endemic 

It means the disease is present in the community at all times but in a relatively low frequency Something that is endemic is typically restricted or peculiar to a locality or region. For example  malaria is endemic in some areas of Africa. 

Epidemic 

An epidemic is a sudden severe outbreak of an infectious disease that spreads rapidly within a  region or group, affecting a large proportion of people. 

Pandemic 

A pandemic occurs when an epidemic becomes widespread and affects a whole region, a  continent or the entire world. 

Clinical disease 

A clinical disease is a disease which has physical manifestations (clinical signs and symptoms). 

Susceptible host 

A susceptible is someone that is exposed to an infectious disease. 

Vector 

A vector is an animal, usually an insect that transmits parasitic microorganisms from person to  person or from infected animals to human beings. 

Transmission cycle 

The transmission cycle describes how organisms grow, multiply and spread. In some cases humans may be the only host, in which case the infection spreads directly from  person to person, e.g. measles. In other cases, humans are the final hosts from whom the  organism has no chance to pass further, e.g. tetanus. 

There are three parts of a transmission cycle for an agent or organism: 

Source —-> Transmission  —-> Susceptible Host 

Source 

The source of an infection can be an infected person or animal, or soil. People and animals may  have clinical disease, subclinical disease or be carriers. 

Transmission 

The main routes of transmission are: 

• ❖ Direct contact (skin, mucous membrane, sexual intercourse) 
• ❖ Vector transmission 
• ❖ Fecal contamination of soil, food and water which are ingested. 
• ❖ Contact with animals or their products (e.g. biting) 
• ❖ Airborne transmission (inhalation) 
• ❖ Transplacental (mother to child) transmission 
• ❖ Blood contact (injections, surgery, blood transfusion) 

Susceptible Host 

A susceptible host is one with low resistance to a particular infection. Low resistance may be due  to: 

•  Not having met the organism before and therefore not having any immunity to it. For  example, at the age of 6-12 months, a child loses the passive immunity against measles  which was acquired from the mother during pregnancy. When in contact with another child who has measles, the child will develop the disease because of no immunity against  measles 
•  Having another serious illness like AIDS at the same time. Such people have a higher risk  of developing tuberculosis. 
•  Malnutrition which can make the infection worse. 

Principles of communicable disease control and prevention 

The aim of control is to tip the balance against the agent. This may be done by: 

1. Attacking the source 
2.  Interrupting route of transmission 
3.  Protecting the host 

Attacking the Source	Interrupting Transmission	Protecting the Host
Treatment	Environmental sanitation	Immunization
Isolation	Personal hygiene	Chemoprophylaxis
Reservoir control	Vector control	Personal protection
Notification	Disinfection and sterilization	Better nutrition