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EMED CONTINUATION OF INFECTIOUS TRANS

SEPTEMBER 2, 2016
HIV / AIDS
Acquired immunodeficiency syndrome (AIDS)
Chronic, potentially life-threatening
condition
Human immunodeficiency virus (HIV)
immune system
HIV interferes host immune system
Sexually transmitted infection
Contact with infected blood
Mother to child during pregnancy ,
childbirth or breast-feeding
Theres no cure fo HIV/AIDS, but medication
slow the progression of the disease
These drugs have reduced AIDS deaths in
many developed nations
But HIV continue to decimate population
in AFRICA, Haiti and parts of Asia
Primary Infection (Acute HIV)
flu-like illness within a month or two after
the virus enters the body may last for a few
weeks .
Possible signs and symptoms include:
Fever
Headache
Muscle aches and joint pain
Rash
Sore throat
Swollen lymph glands, mainly on the
neck

Chronic Latent Infection (Chronic HIV)


Persistent swelling of lymph nodes
No specific signs and symptoms
HIV remain in the body, in fected white
blood cells
Lasts around 10 years if not receiving
antiretroviral medications
Progress to more severe disease much
sooner
Clinical Latent Infection (Chronic HIV)
Persistent swelling of lymph nodes
No specific signs and symptoms
HIV remains in the body , in infeted
white blood cells
Lasts around 10 years if not receiving
antiretroviral therapy
This phase can last for decades in
people taking antiretroviral
medications
progress to more evere disease much
sooner.
Early symptomatic HIV infection

Primary HIV infection may be mild enough to go


unnoticed the amount of virus in the
bloodstream (Viral load ) is particularly hig all
this time
HIV infection spreads more efficiently during
primary infection than during the next stage of
infection.

To God be the Glory! 2016

Virus continues to multiply and destroy


immune cells, develop mild infections
or chronic signs and symptoms such
as:
Fever
Fatigue
Swollen lymph nodes - often
one of the first signs if HIV
infection
Diarrhea
Weight loss
Oral yeast infection (thrush)
Shingles (herpes zoster)

Progression to AIDS

If no treatment if typically progresses


to AIDS in about 10 years

By the time AIDS develops become


susceptible to opportunistic infections
diseases that wouldnt usually
trouble a person with a healthy immune
system .
The signs and symptoms of some of these
infections may include :
Soaking night sweats
Recurring fever
Persistent white spots or unusual
lesions on your tongue or in your
mouth
Persistent , unexplained fatigue
Weight loss
Skin rashes s or bumps

A tumor of the blood vessel walls common in


HIV-positive
Appears as pink, red or purple lesions
on the skin and mouth
In people with darker skin, the lesions
may look dark brown r black
The internal organs , including the
digestive tract and lungs
Lymphomas

The most common early sign is painless


swelling of the lymph nodes in your neck,
armpit or groin

Other complications

COMPLICATIONS
Infections common to HIV/AIDS
Tuberculosis (TB)- the most common
opportunistic infection associated with
HIV and a leading cause of death
among people with AIDS.
Cytomegalovirus - herpes virus
causing damage to your eyes ,
digestive tract, lungs or other organs
Candidiasis white coating on the
mucous membranes of your mouth,
tounge, esophagus or vagina
Cryptococcal meningitis fungal
infection common in central nervous
system infection
Toxoplasmosis Toxoplasma gondii, a
parasite spread primarily by cats
Cryptosporidosis ingestion of
contaminated food or water leading to
severe, chronic diarrhea in people with
AIDS

Wasting syndrome a loss of at least 10


percent of body weight , often
accompanied by diarrhea, chronic
weakness and fever

Neurological complications as confusion ,


forgetfulness, depression, anxiety and
difficulty walking, AIDS dementia complex
which leads to behaviour changes and
diminished mental functioning
Kidney disease HIV associated
nephropathy (HIVAN) higher in blacks

Regardless of CD4 count, antiretroviral therapy


should be started in those diagnosed with
HIV/AN.

DENGUE HANDBOOK FOR CLINICAL


MANAGEMENT OF DENGUE

CRITERIA FOR DENGUE AND WARNING SIGNS


Cancers common to HIV/ AIDS :
Probable dengue
Kaposis Sarcoma
Live in / travel to

To God be the Glory! 2016

Fever and
Nausea, vomiting
Rash
Aches and pains
Tourniquet test positive
Leukemia
Any warning sign

encephalopathy, or encephalitis or other


unusual manifestation or other unusual
manifestation

CASE DEFINITIONS
Suspect case

Laboratory -confirmed dengue

WARNING SIGNS
Abdominal ___ tenderness
Pe
Clinical fluid accumulation
Mucosal bleed
Lethargy , restlessness
Liver enlargement > 2 cm
Laboratory : Increase in HCT ____ with
rapid decrease in platelet )))
___

Is the lesion
Blurred
Pic
purulent ?

Pic

*blurred pic
PANDEMIC INFLUENZA
CRITERIA FOR SEVERE D
Severe plasma leakage
Leading to :
Shock (DSS)
Fluid accumulation with respiratory
distress
Severe bleeding
As evaluated by clinician
Severe organ involvement
Liver ASTand ALT = 1000
CNS Improved consciousness
Heart and other organs

Global outbreak of disease, but does


not need to be severe to be a
pandemic
Essential features:
- it is a novel human subtype
Virus can replicate and cause disease
in humans
-Efficient person spread

CLINICAL STAGE OF TETANUS


CRITERIA

>Theres a significant bleeding


> There is an altered level of consciousness
lethargy or restless convulsion)
> There is an altered level of consciousness
(lethargy or restless convulsions)
> There is severe gastrointestinal organ
impairment (acute liver failure, acute

To God be the Glory! 2016

Incubatio
n period
Period of
onset
Trismus
(difficulty

STAGE
1
>11
days
>
7days
Mild
or

STAGE II

STAGE III

8-10 days

, 7 days

4-6 days

>3 days

Moderate

Present

in opening
of mouth )
Dysphagia
(difficulty
of
swallowin
g)
Muscular
rigidity
Proxysmal
spasm

Sympathe
tic
overacting

Dyspnea
or
cyanosis

absent
Absent

Present

Mild or Pronounc
localize ed
d
Absent Mild or
short

Absent

Short

Present

Severe,
board-like
Frequent ,
violent ,
prolonged
asphyxia,
Unstable
BP,
(hypertensi
on,
hypotension
)
paroxysmal
tachycardia
, & other
cardiac
dysrhythmia
s ) profuse
sweating
,hyperpyrexi
a )
Present

Flow Diagram
Outpatient Diagnosis & management of Suspected
CAMRSA Skin and Soft tissue Infections

To God be the Glory! 2016

Symptoms of Skin & Soft tissue infections ;


Compliant of spider bite ;
Redness swelling warmth,
Pain. tenderness
Furuncles/ Carbuncle /Folliculitis
Abscess
Infected Wound
Impetigo

Im

Type of
Local
Environment Effects

Systemic Effects

Snake

Neurotoxic

Slow
swelling
then
necrosis

Ptosis ,
COBRA
glossopharryngeal
palsy, respiratory
paralysis, cardiac
effects hypotension ,
bradycardia,
dysrhythmias

Myotoxic

NONE

Myalgua, on
moving,
myoglobinuria,
hyperkalemia,

Sea
shake

Vasculotoxic

Rapid
swelling,
then
necrosis

Abnormal
bleeding , nonclotting blood ,
shock,

Vipers

EBOLA IN WEST AFRICA

Long narrow virus length 1400 nm & width


80 nm
Filamentous
RNA with protein as inner core, atrix layer
next then membrane from host cell
outside
RNA codes for 8 proteins
Virus takes over the cell
FIlovirus family (FIloviridae )
Zaire Ebola virus
Sudan Ebolavirus
Bundibugyo Ebolavirus
Taiforest Ebolavirus
Reston Ebola virus

Chain of Infection certain conditions must


be met in order for a microbe or infectious
disease to be spread from person to person
Chain of infection Model

Staphylococcus aureus
Pic

Secondary spread to all organs


Exits the body in feces, saliva, sweat,
tears, sputum, skin cells, breast milk,
semen, urine
SURVIVAL OUTSIDE HOST
Dried :
24 hr at 25 C ; 14 days at 14 C
In fluids:
Up to 46 days at 25 C
Ebolavirus is killed by:
> heat at 60 C for 1 hr
> Alcohols
> 3% acetic acid
> 1% glutaraldehyde
Handwashing with soap & water will kill
Ebolavirus

FINDING THE TRUE SOURCE (RESERVOIR ) OF


THE DISEASE
No answer yet
What is the reservoir of the disease
?
What caused the pigs to get the
Ebola Reston virus ?
The effectiveness of disease control
measures depends on finding the source of
Ebola reston virus
PATHOGENESIS OF EBOLAVIRUS

EBOLA VIRUS

NATURAL HISTORY
Virus enters the cell
>Any cell, but particularly uses
macrophages , dendritic cells &
monocytes
Spreads to lymph nodes via lymphatics
& then to liver & spleen via blood

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Destroy cells
Focal necrosis in many organs
Suppress inflammation
Cause cytokine storm
Induced clotting
Multi-organ focal necrosis & disseminated
intravascular coagulation with focal
hemorrhage & minimal inflammation
TRANSMISSION OF EBOLA VIRUSES

Droplet infection
Direct contact
with infected cynomolgus monkeys
(Macacca fascicularis) or crab- eating
macaques
With dead carcassess of infected
animals
particularly with the blood
secretions, organs or other bodily fluids
Sexual transmission

PATIENT SCREENING & TRIAGE


The objective of screening is to quickly
identify people with a travel history o
countries with ongoing transmission
of Ebola
The objective of triage is to determine
if these oersons have symptoms of
EVD & if so, to promptly isolate them
Perosnnel in health facilities at first points
of contact should be trained on EVD
screening procedures
Tirage should be done by health care
personnel

Ebola & the Chain of Infection in Healthcare


facilities
Pathogenic microorganism
> Ebola virus
Reservoir
> Patient infected with Ebola
Mode of Escape
> blood & body fluids
Mode of Transmission
> Contact with bloody & body fluid
of infected person
> Contact with
Mode of entry -

TREATMENT
Objective

To God be the Glory! 2016

to provide optimal care to the


patient with maximal protection of the
health care personnel
NO FDA-approved vaccines or
medicines available for ebola
Treatment is mainly supportive &
symptomatic
--fluid balance
-- nutrition
-- managing hemorrhagic complications

RESTON EBOLAVIRUS
The Good Cousin
Found in the Philippines & China
Causes respiratory disease in pigs
Infects human, but No disease
> pig, farmers, abattoir workers , others
have antibodies

Middle East Respiratory Syndrome Corona


Virus ( MERS-CoV)
> Case demographics
Males > females
Median age 49 years ( 9 months - 94
years)
Incubation period 2 -14 days
Infection period 2-14 days
Under investigation
Not believed to be contagious
before onset
1st identified in September 2012
Cases retrospectively identified as early
as March 2012
Different from other coronaviruses in
humans, including SARS
Most similar to corona viruses found in
bats

Treatment largely supportive and should


be based on the patients clinical condition
Medical care is spportive and should be
based on the patients clinical condition
Medical care is supportive and to help
relieve symptoms
Currently, there is no available vaccine
against MERSCoV

Several studies have identified MERS-CoV in


high proportion of camels
likely reservoir

Increased virulence (group a Strep )


Jumping species from animals to humans
(avian influenza, HIV , SARS?)
MERS- CoV
Its not always possible to identify
patients with MERS-CoV early because
some have mild or unusual symptoms
It is important that health care
workers apply standard precautions
consistently with all patients
regardless of their diagnosis in all
work practice all the time

> Identical gene segment found in one bat

Mode of transmission is unclear


Respiratory ?
Foodborne?
Few primary cases with direct
camel contact

75% identified as secondary


> mostly healthcare workers (19% of
all cases)
> Many with no or minor symptoms
Many clusters identified
> healthcare
> Household (estimated 1.3 %
secondary attack rate )

Infection Control
No sustained human to human
transmission
What ? Breaking the chain of infection .
Why? Prevent infections with health
facilities
How Consistent practice of protocols
that prevent any infectious agent
moving from one host to another
Who? Protects
Patients
HCWs
Visitors
Other staff
Microbial Adaptation & Change
Increased antibiotic resistance with
increased use of antibiotics in humans and
food animals (VRE, VRSA penicillin and
macrolide resistant Strep-pneumonia ,
multidrug resistant Salmonella)

To God be the Glory! 2016

Wash your hands often with soap and


water for 20 seconds and help young
children do the same
If soap and water are not available,
use an alcohol-based hand sanitizer
Cover your nose and mouth with a
tissue when you cough or sneeze then
throw the tissue in the trash
Avoid touching your eyes, nose and
mouth with unwashed hands
Avoid close contact , such as kissing ,
sharing cups or sharing eating utensils,
with sick people
Clean and disinfect frequently touched
surfaces , such as toys and doorknobs

CORONA VIRUSES

Human CoVs first isolated in the 1960s


Six human CoVs identified to date
HCoV -229E
HCoV OC43
HCoV NL63
HCoV HkU1
SARS CoV
Middle east Respiratory Sydnrome
Coronavirus (MersCov)

HEALTH-ACQUIRED versus Communityacquired MRSA


HA-MRSA

Skin & soft


tissue
Respiratory
tract
Otitis media
Urinary tract
Bloodstream
Other

CA-MRSA

- Recent
hospitalization
or surgery
Living in a
nursing home
-carrying an
indwelling
catheter or
device

Disease
condition

-Nosocomial
pneumonia
-Bacteremia

(+) Panton
Valentin
Leukocidin
Enzyme
Antimicrobial
resistance

- Bow (< 2%)

Multidrug
resistant

-Necrotizing
pneumonia
-Skin & soft
tissue
infection
- Almost 100%

Pauciresistant
but more
invasive

COMPARISON OF disease presentation


between HA-MRSA & CA MRSA
Infected area

HA-MSA (%)

CA MRSA
(%)

To God be the Glory! 2016

74

22

6
7

20
9
13

4
9

CA- MRSA
Outpatient treatment recommendations

Risk Factors

36

No single agent demonstrates superiority:


use sensitivities to guide therapy if
available
Doxyxycline 100 mg PO BID for 10-14 day
(not for use in pregnant women or in
children ) or
Clindamycin 300-600 mg PO q8h for 1014 d or
Trimethoprim sulfamethoxazole (160 mg/
800mg) DS 2 tablets PO BID for 10-14 d
Some CA-MRSA strais have inducible
resitance & this may result in treatment
failure , A D-test can be performed by
microbiology to look for this

CASE DEFINITIONS
Person under Investigation (PUI)
> Any person who has resided in or
travled to any of the countries with
ongoing widespread EVD transmission
in the past 21 days
OR
Any person who had significant contact
with a suspect / probable/ confirmed
EVD case in the past 21 days
AVIAN INFLUENZA (H5N1)
The virus is not fully adapted to human
High case fatality rate (60%)

Ensure political support


Ensure judicious use of antibiotics
Vaccines for all

Human to human transmission nnot


sustained

SARS
Incubation period : 2-10 days

HUMAN DEMOGRPAHICS , BEHAVIOR


VULNERABILITY

Droplet transmission
Aerosol spread
Fomites
Fecal- respiratory transmission at
an apartment complex in Hongkong
Transmission most likely during 2nd week
of illness
Super spreading events

More people , more crowding


Changing sexual mores (HIV, STDs)
Injection drug use (HIV, Hepatitis C)
Changing eating habits out more , more
produce (foodborne infections)
More populations with weakened immune
system ,elderly , HIV/ AIDS , cancer
patients and survivors, persons taking
antibiotics and other drugs
PUBLIC HEALTH RISKS

1ST recognized in Nov. 2002 as sporadic


cases in Guangdong province , China
Outbreak period 2002- 2003
Hong kong hotel contributed to spread
of virus to several countries

NON- SARS Human CoVs


Most often associated with upper
respiratory tract infections in children
Pneumonia & lower tract infections in
immunocompromised individuals &
the elderly
May play a role in exacerbations of
underlying respiratory diseases

Virus could be transmitted to


humans
Virus has ability to undergo
frequent & permanent changes
that must be monitored
Ability to swap or re-assort genetic
material & merge
* facilitate human- to human
transmission that may lead to
pandemic
Rapid spread from one person to
another
No immunity
No existing vaccines
Prevention of Merging Infectious Disease will
Require Action in Each of these Areas

PREVENTING EMERGING INFECTIOUS


DISEASES : MORE TO DO

Enhance communication : locally,


regionally, nationally, globally
Increase global collaboration
Share technical expertise and resources
Provide training and infrastructure
support globally

To God be the Glory! 2016

Surveillance & Response


Applied Research
Infrastructure & training
Prevention & control

INTERNATIONAL TRAVEL & COMMERCE

Persons infected with an exotic disease


anywhere in the world can be into
another country within hours (SARS,)
Food from other countries imported
routinely (Cyclospora ..)
Vectors hitchhiking on imported
products ( Asian tiger, mosquitoes)

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To God be the Glory! 2016